Obgy INSTRUMENTS DRUGS SPECIMENS MBBS FINAL YEAR.pdf

“The person who gets the farthest is
generally the one who is willing to
do and dare. The sure-thing boat
never gets far from shore.”

SIM’S SPECULUM
James Marion Sims ( USA )
A) PARTS–a)Blades-Single /Double, Curved
b) Handle-Grooved
B) METHOD OF APPLICATION
Sim’sposition / Dorsal position with buttocks
at the end of table
No need of anesthesia
Along with anterior vaginal wall retractor
Introduced in AP diameter , rotated in 90
degrees

C) USES
a) Gynecology
Routine examination, for visualization of cervix,
vagina.
Collect vaginal discharge for investigation
OPD procedures –IUCD insertion & removal, Pap
smear , IUI.
Diagnostic
Hysterosalphingography, Sonosalphingography
Operations
Minor –D & C, polypectomy, hysteroscopy
Major –Vaginal hysterectomy

b) Obstetrics
First trimester-
, evacuation & curettage, MVA , suction evacuation of
vesicular mole
Second & third trimester-
Evaluation of APH, cervical encirclage, intracervical
catheterization
Puerperal-
Diagnosis & repair of cervical laceration
D)ADVANTAGES
Ideal for OPD examination
E)DISADVANTAGES
Needs AV retractor for better visualization, assistant
required otprocedures
F)CONTRAINDICATION
Unmarried
G)STERILISATION–Autoclaving , boiling

SIM’S ANTERIOR VAGINAL WALL
RETRACTOR
A)PARTS–Angulated fenestrated ends(15
degree angle)
B)METHOD OF APPLICATION
After introducing Sim’sspeculum, AV
retractor is held in right hand with angle of
fenestrumfacing upwards
C)USES
With Sim’sspeculum
D)STERILISATION
Autoclaving in OT, boiling in OPD

NOTE
Angulated
fenestrated tip

CUSCO’S BIVALVED SELF RETAINING
VAGINAL SPECULUM
A)PARTS–Two hinged blades, screw
B)METHOD OF APPLICATION
Lubricated introduced in AP diameter of vagina,
rotated in 90 degrees, blade opened & fixed
with the help of screw
C)USES
Per speculum examination
OPD procedures –pap smear(Ideal speculum),
IUI, colposcopy
NOT used for major/ minor gynecological
operations

D)ADVANTAGES
Self retaining, assistant not required ,can be
used in any position, can be adjusted to the side
of vagina
E) DISADVANTAGES
Can not visualize anterior & posterior vaginal
wall
Space available is limited for carrying out
procedures
F) STERILISATION
Autoclaving

HEGAR’S DILATORS
A)PARTS–
Curvedtip, single/ Double bladed
Setof 12 dilators cover all diameters from 3-26 mm
B) METHOD OF APPLICATION
Held in center between index finger below & thumb
upside
Dilatation with gradual number of dilators by to &
frowmovements
C)USES
a)Gynaecology
Asa part of D & C
Before hysteroscopy

Diagnosis of incompetent os-Passage of no 8 Hegar’s
dilator without resistance without causing pain or
discomfort
Therapeutic in cervical stenosis
In Fothergill’s operation before amputation of cervix
Drainage of pyometra/ Lochimetra
b) Obstetrics
Before curettage
Newton’s formula
Cervical dilatation= Gestational age (Wk)+ 0.5
D) COMPLICATIONS-Cervical lacerations, false passage,
uterine perforation, cervix incompetence
E) STERILISATION-Autoclaving

UTERINE CURETTE
A)PARTS–
Fenestrated loops(Single/ Double)-sharp/ blunt
Sizes 4-10 mm
Serrated Handle
B) METHOD OF APPLICATION
Held in center between index finger below & thumb
upside
Tip of index finger should be at a distance equal to
UCL
C)USES
a)Gynaecology(Sharp curette)
1) Diagnostic
Evaluation of DUB, TB endometritis, post menopausal
bleeding, infertility, Ca cx( endocervicalcurettage)

With polypectomy, part of Fothergill’s repair
2)Therapeutic
In DUB , Asherman’ssyndrome
b) Obstetrics
Bluntcurettage for incomplete,missed,
inevitable, septic abortion
Puerperal curettage-Retained POCs
D)Sample to be sent in formalin bulb for HPE
TB-In Normal saline for culture & formalin for
HPE
E) COMPLICATIONS-Uterine perforation,
Hemorrhage
F) STERILISATION-Autoclaving

SHARP END OF CURETTE
BLUNT END OF CURETTE

UTERINE SOUND/ HYSTEROMETER
A)PARTS–
Handle & blunt olive tip
12 inches in length, 2 mm in diameter angulation
2.5 inch from blunt tip
B) METHOD OF APPLICATION
DoPV examination before sounding
DoPS ,catch hold anterior lip of cx
Hold sound like pen with little finger extended to
prevent perforation
C)USES
To determine length& direction of uterocervical
canal before D & C, insertion of IUCD

Evaluation of misplaced CuT
Todistinguish between chronic inversion &
pedunculatedpolyp
To manipulate uterine cavity during laparoscopy
Jakarta’s test –In suspected vesicular mole if
sound can be rotated all around in uterine cavity
& inserted for more than 11 cm test is positive
Clarke’s test-In endometrial carcinoma passage
of sound produces bleeding
D)CONTRAINDICATIONS-In suspected / confirmed
pregnancy
E) COMPLICATIONS-Uterine perforation,
Hemorrhage
F) STERILISATION-Autoclaving

NOTE
Olive tip
Angulationand serration(markings) on handle

BLADDER SOUND
A)PARTS–
Handle & blunt tip (No olive tip)
25cm in length, doesn’t have graduations
B)USES
To definelimits of bladder during operations like
anterior colporrhaphy, Kellies stitch for SUI repair
To confirm suspected bladder injury during vaginal
hysterectomy
To determine length & direction of vesicovaginal
fistula
Tosound foreign body in bladder
Todifferentiate bladder or urethral diverticulum
from anterior vaginal wall cyst
C) STERILISATION-Autoclaving

NOTE:
•Blunt end
•Smooth curve
•No serrations/markings

KOCHER’S PEDICLECLAMP
A)PARTS–
Business end having transverse serrations on it with rat
teeth at its tip
B)USES
a) Gynaecology
To clamp pedicleduring hysterectomy
(abdominal/vaginal)
To clamp pedicle of pedunculatedfibroid in myomectomy
To clamp pedicle of ovarian tumour/ cyst
Tosteady the uterus during abdominal hysterectomy
b) Obstetrics
To clamp pedicle during obstetric hysterectomy
Artificial rupture of membranes
Clamping of umbilical cord
C) STERILISATION-Autoclaving

NOTE
Transverse serrations and 2*1 tooth at tip

HEMOSTIC FORCEP
•It is called “peang” after Jules Emile Pean.
•TYPES: Straight, curved. Small ,medium ,large.
•PARTS : Business end :Tapering ands with transverse
serrations on inner side for hemostasis.
•Handle at proximal end with finger grip and catch with
3 ratchets first merely catches tissue, second clamps
tissue third crushes tissue creating hemostasis
•Blades with cross joint .
•Artery is the misnomer used.
•When holding structures on surface straight hemostat
is used, in deep pelvic cavity curved one is used.

NOTE
TRANSEVERSE SERRATIONS

Curved artery forceps being used for holding ends of suture material

USES
•To secure bleeder before ligation or cauterization
for hemostasis.
•To hold parietal / visceral peritoneum
•To hold ligatures to be kept long.
•Kelly’s hemostat is used as clamp.
•To crush the base of fallopian tube in tubal
ligation.
•Used to separate tissue planes e.g. to separate
myomafrom pseudocapsule.
•Small peanut held at the tip is used for blunt
dissection of loose aereolartissue : exposing
anterior longitudinal ligament in sling surgeries.

PUNCH BIOPSY FORCEP
•Parts: Business parts: Cup shaped in Gelhorns
and square jaw in Alligators types . Upper cup
has sharp cutting edge lower cup holds the
tissue.
•Proximal end : finger rings with handle at
right angle to shank.
•Shank: two arms with cross joint.

USES
•Cervical punch biopsy
•vaginal punch biopsy
•vulvalpunch biopsy
•Biopsy is taken from the edge of the ulcer or growth.It
should also include normally looking area. 2-3 pieces
should be punched out from different areas.
•Centre of the growth is necrotic so not a good area for
biopsy.
•If bleeding occurs: apply pressure, cauterise, take
figure of 8 suture with chromic catgut.

ALLIS FORCEPS
•Parts : Business end: Tips are curved inside
and have 4-5 rat teeth which fit in one
another for a firm grip of tissue.
•Proximal end: finger grips and ratchet lock .
•Shank: 2 arms with box joint.
•USES : To hold rectus sheath while opening
and closing the abdominal wall.

NOTE
Multiple teeth at the tip of forcep

Allis forceps used for holding angle of rectus sheath

•GYNECOLOGICAL: In anterior colporrhaphy, enterocele
repair, colpoperinearrhyphy
•In vaginal hysterectomy during opening of anterior and
posterior pouches , during closure of vagina.
•Fothergillsrepair
•Abdominal hysterectomy after opening vaginato
facilitate circumcising cervix and to draw up the cx
after opening the vault.
•Dissection of vaginal cuff in abdominoperinealrepair.
•In the repair of vesicovaginalfistula/recovaginalfistula.
•To hold the cxin trachleorrhaphy.
•In vaginal hysterectomy to deliver fundusthrough
either of the pouches.
•Utriculoplastywhile suturing the cut horns of uterus.

•OBSTETRICS: In cesarean section to hold the
angles of incision.
•To catch the apex of episiotomy incision while
suturing episiotomy.
•For correction of acute inversion of uterus by
abdominal operation.
•To hold quadrants of cervix during encirclage.
•OTHER : Marchettitest in stress incontinence
To hold vas deference in vasectomy.

BABCOCK’S FORCEPS
•Parts: business end: Semicircular fenestrated
atraumaticends which when approximated
can hold a tubular structure.
•Proximal end: finger rings and ratchet lock.
•Shank: 2 arms with box joint
•3sizes; small, medium, large.

USES :
•To hold fallopian tubes in tubal sterilization ,ruptured tubal
ectopic pregnancy, tuboplasty.
•Round ligaments in round ligament plication.
•Ovaries in conservative operations on ovaries like
adhesionolysis, ovarian biopsy, ovarian ectopic pregnancy,
cystectomy,wedge resection.
•In wherthiem’shysterectomy to hold uretersand pelvic
lymph nodes.
•To hold bowel in repair of rectovaginalfistula ,third degree
perinealrepair.
•To hold bladder in repair of vesicovaginal fistula.
•OTHER: To hold vas in vasectomy
To hold appendix, ceacum

NOTE
Triangular tip with groove and fenestra

Babcocksforceps used for holding fallopian tube

Babcocksforceps used for holding round ligament

Babcocksforceps used for holding ovary

SPONGE HOLDING FORCEPS
•PARTS: Business end round fenestrated with
transverse serrations.
•Proximal end: finger rings with ratchet lock
•Shank : 2 arms cross joint .
•USES: General : Painting and preparing parts
preoperatively.
•Swab out vagina and pelvic cavity.

NOTE
round fenestrated with transverse serrations.
(non traumatic)

Sponge holding forceps used for painting before
operative procedures

USES IN GYNECOLOGY:
•To apply pressure by means of sponge over deep
bleeding point during pelvic surgery, to check
hemostasis.
•For packing away omentumandintestines out of
pelvis.
•Temporary clamping of infundibulopelvic
ligament during haemorrhagein myomectomy.
•Graduated sponge is used in POP-Q quantification
of prolapse.

USES IN OBSTETRICS: To hold gravid cervix
during encirclage.
•To hold cervix for tracing cervical tear after
vaginal delivery.
•During cesarean section: To push down the
bladder, to hold the edges of uterus and to
swab out blood, muconiumfrom abdomen.
•To deliver fallopian tubes in puerperialtubal
ligation.

OVUM FORCEPS
•Named after Haywood Smith
•Stainless steel
•PARTS: Business end: Cup shaped oval fenestrated
ends.
•Proximal end : finger rings and no catch.
•Shank:2 arms with cross joint
•USES: To remove products of conception when more
than 10 wks of incomplete/inevitable, missed abortion
.
•Evacuation of vesicular mole.
•To remove bits of placenta,membranesfrom gravid
uterus, foreign body from uterus.
•To twist off pedunculaterpolyp.

NOTE
Oval end with vertical serrations

GREEN ARMYTAGE FORCEPS
•PARTS:Businessend: Flat, transverse triangular
with transverse serrations.
•Proximal end: Finger rings with ratchet lock.
•Shank : 2 arms with box joint
•TYPES : Straight, curved.
•USES:Tograsp the lower edge of the lower
uterine segment in lscs.Thisachieves hemostasis
by compressing bleeding vessel.
•To trace cervical tear after vaginal delivery.
•Advantages: Atruamatic, hemostatic,canlift up
the edges of uterus foeasy suturing.
•Disadvantages: Sponge forcepis used now a days
for tracing cervical tear after vaginal delivery.//

NOTE
Flat, transverse triangular with transverse serrations at tip

Vulsellum
Features : long curved instrument which has tip
with multiple sharp rat teeth which gives firm
grip.
Uses : designed to hold lip of gynecological cervix-
Anterior lip held in: endometrial biopsy, insertion of
IUD, intra uterine insemination, vaginal
hysterectomy, cauterization of cervix, cervix
biopsy.
Posterior lip held in : colpo-puncture, culdoscopy,
posterior colpotomy, biopsy from anterior lip of
cervix.
Other uses: for grasping fibroids in myomectomy, to
hold cervical stumps after amputation of cervix.

NOTE
curved blades for better visuatisation

NOTE
Multiple teeth at tip

Tissue forceps(dissecting forcep/thumb forcep)
Features : serrations on handle for better grip
and handle with spring like action.
Uses :
1.Tooth forceps : to grasp tuoghstructures like
rectus sheath fascia, vaginal wall.
2.Plain forceps : To grasp structures like
peritoneum and muscles.
3.To hold tissue in place while applying suture.
4.To hold suture ends while suture removal.

Plain forceps
Toothed forceps

Plain forceps for holding peritoneum
Toothed forceps for holding rectus sheath

SHIRODKAR’S UTERUS HOLDING FORCEPS
A)PARTS–
Curved transeverseblades, handle with ratchet lock
B) METHOD OF APPLICATION
Opened blades are passed from top over the fundus
till they reach isthmus, which is clamped in
anteroposteriorly
C)USES
Tosteady & manipulate uterus in tuboplasty,
Shirodkar’sabdomonaltubal patency test,
conservative operations of adnexae.g.
salphingectomyfor tubal ectopic, ovarian surgery,
Moschowitzenterocoelerepair,uterosacralligament
plication
D) STERILISATION-Autoclaving

Bonney’smyomectomyclamp
Features : two sets of rings proximal and distal
Uses : for obliteration of B/L uterine artery
while,
•Abdominal myomectomy
•Utriculoplasty
When to release clamp-
every 15 mins
Every 10 minsif ovarian ligament are clamped.
Contraindication: removal of cervical or ischemic
fibroid

Business end
Handle

NEEDLEHOLDER
A)PARTS–
Business end with inner surface with crisscross
serrations with a longitudinal groove, box joint
nearer to business end, handle with ratchet lock
B) METHOD OF USE
Curved needle held caught at a distance of 2/3 rd
from joint with needle held at a distance of 2/3 rd
from tip.
C)USES
Tohold needle during suturing
Can be used as hemostat
D) STERILISATION-Autoclaving

NOTE
Crisscross serrations and longitudinal groove

Needle holder is used for holding needle while suturing tissue

TOWEL CLIP
Doyen’s cross action towel clip
•‘g’ shaped .
•Curved blades cross near business end ending
in sharp teeth.
•When the handle with spring like action is
pressed the tips open out and on release of
pressure the teeth get approximated. Blades
are flat.

Mayo’s towel clip
Figure of 8 towel
clip

USES
•To drape the surgical area after paintingthe
parts in abdominal or vaginal procedure.
•To fix the suction tube, cauterywire or cords
to the drapes.

EPISIOTOMY SCISSORS
•It is a pair of angulated scissors.
•PARTS: Business end: Appointed end that goes
inside vagina and a blunt end that lies outside
vagina on perinealskin.
Proximal end :finger rings on same side.
Flat blades with cross joint. It is angulated to
keep hand away from perineum.
USES: To give episiotomy.

NOTE
Angulationat blades

NOTE
Blunt and sharp tips of blades

Operative vaginal delivery

Simpsons
Piper

Cephalic Curve

Pelvic Curve
Functions
Parts

Types of Vacuum

Classification of OVD
•Outlet
–Scalp visible @ introitus w/o separating labia
–Fetal skull @ pelvic floor
–Saggital suture in AP plane (or ROA/LOA)
–Fetal head at or on perineum
–Rotation < 45 degrees
•Low
–Leading point of fetal skull > or = +2 station
–Rotation < 45 degrees
–Rotation > 45 degrees
•Mid
–Station above +2 station but the head is engaged
•High
–Not included in classification

Indications for OVD
No indication is absolute
•Prolonged 2
nd
stage
–Nulliparous: lack of continuous progress
•>3hrs with regional anesthesia
•>2hrs w/o regional anesthesia
–Multiparous: lack of continuous progress
•>2hrs with regional anesthesia
•>1hr w/o regional anesthesia
•Fetal compromise
•Maternal benefit to shortened 2
nd
stage

Indications for forceps delivery
•Foetal indications: -
–Foetal distress in second stage when prospect of vaginal
delivery is safe: -
•Abnormal heart rate pattern
•Passage of meconium
•Abnormal scalp blood ph
–Cord prolapse in second stage
–Aftercoming head of breech
–Low birth wt. Baby
–Post maturity

Indications for forceps delivery
•Maternal indication: -
–Maternal distress
–Pre-eclampsia
–Post caesarian pregnancy
–Heart diseases
–Intra partum infection
–Neurological disorders where voluntary efforts are
contraindicated or impossible

Safe practice: prerequisites for
instrumental delivery
•Fully dilated cervix
•One-fifth or nil palpable abdominally
•Ruptured membranes
•Contractions present
•Empty bladder
•Presentation and position known
•Satisfactory analgesia

Insertion

Vacuum Placement
•Proper cup placement is the most important
determinant of success in vacuum extraction.
•The center of the cup should be over the sagittal
suture and about 3 cm in front of the posterior
fontanelle toward the face –median flexion point.

DOYEN’S RETRACTOR
•Parts: BUSSINESS END: Stout broad transverse
end curved with hollow towards handle.
•HANDLE: Finger grips are present with curved
end
•SIZES: Small,medium,large.

•METHODS: After opening peritoneal cavity,
doyens retractor covered with wet mop is
inserted to retrctthe abdominal wall to avoid
trauma
•ADVANTAGES : Hemostaticfunction: the stout
blade compresses the edges of the abdominal
incision creating temonadeeffect.
•DISADVANTAGES: Does not retract bladder well.
•Space occupying when large size used.

Doyens retractor used for retraction of bladder in
lower segment cesarean section

Uses :
To retract lower abdominal wall.
•GYNECOLOGY : Abdominal hysterectomy ,
tuboplasty, Shirodkarssling, Purandare’s
cervicopexy, Virkudscomposite sling, Khana
sling, exploratory laparotomyfor ovarian
tumourmyomectomy, Wertheims
hysterectomy
•OBSTETRICS: Cesarean section , exploratory
laparotomyin ruptured ectopic, cesarean
hysterectomy.

DEAVER’S RETRACTOR
•Business end:Anarrow graduallycurvedc
shaped blade with blunt end.
•Proximal end: Acutely curved tip for hand grip.
•Handle is straight.
•SIZES:Small, medium,large.
•METHOD:afteropeninperitoneal cavity,the
omentumand bowel are packedwithisolation
mops and deaver’sretractor covered with
mop is inserted to retract the intraperitoneal
structures.

USES
•To retract sides of abdominal incision and
intraabdominalstructuresinprocedures:
abdominal hysterectomy, Shirodkar’ssling
operation,Wirkud’ssling operation,exploratory
laparotomyfor ovarian tumour, Werthiem’s
hysterectomy.

RIGHT ANGLE RETRACTOR
•Also named as Landon bladder retractor.
•It is L shaped.
•PARTS: Business end 2 cm broad flat blade
with curved or flat end. Curved end prevents
injury to bladder. Handle has circular opening
in centre for introduction of finer for better
grip
•Advanages: Blade being flat and narrow
occupies less space in the anterior pouch it is
good for vaginal surgeries.

USES
•To retract bladder away from uterus and
cervix during vaginal hysterectomy. It prevents
injury to bladder and ureterduring clamping
of uterine vessels .
•To retract lateral anterior vaginal walls during
any vaginal operation.

Right angle retractor is used for abdominal wall

Roux’s ‘C’ shaped retractor
Feature: stout handle in middle and blades are
curved.
Uses :
To retract sides of anterior abdominal wall in
mini-laparotomyand exploratory laparotomy.

SCALPEL HANDLE
A)TYPES
Disposable/ Non disposable(common)
Resharpenable/ with replaceable blades (common)
Flat handle( #3 & #4),rounded & flat(#7)
B) METHOD OF USE
a) Palmer grip/dinner knife-
Handle held with second through fourth finger
Bestfor initial incision & larger cuts
b) Pencil grip-
Handle held with tips of first & second & tip of the
thumb with the handle resting on fleshy base
Best for more precise cuts
C) STERILISATION-Autoclaving

Barb Parker’s handle and sugicalblade is being used
for skin incision

SURGICALBLADES
A)TYPES
# 10–curved cutting edge with flat back
# 11 -triangular blade with sharp point & flat cutting
edge parallel to handle & flat back
# 15 –smaller version of #10
# 20 –large, broad
B)USES
# 10 , # 20 –for making skin incision
# 11 –for incision & drainage
# 15 –for making fine incisions

FOLEY’S CATHETER
A)PARTS–
40 cm length self retaining, from 12-30 French
French represents diameter-external diameter in mm
is 1/3 of catheter number
Made up of latex/ silicon/ polythene
Two channels one for inflation of balloon other for
drainage of urine
B) METHOD OF USE
Introduced under all aseptic precautions till the bulb
is well inside bladder
Bulb inflated with normal Saline/ sterile water just
enough to retain it inside bladder.
Removed after deflating catheter, if can not be
deflated bulb rupturedby excessive deflation/
injecting NaHCO3

B)USES
a) Obstetrics
To relieve retention of urine in retrovertedgravid
uterus
For instillation of ethacrydinelactate solution for
second trimester MTP
To replace bulging membranes during cirvical
encirclageoperation
Treatment of atonicPPH
Preoperative catheterization to avoid bladder injury
Mechanical method for induction of labour

b) Gynaecology
To relieve retention of urine in pelvic tumours
To perform hysterosalphingography
Conservative treatment of vesicovaginalfistula
( catheter for 3-6 wks)
To test tubal patency during tuboplasty
paediatricfoleyscatheter is used
Treatment of Asherman’ssyndrome
To improve visualisationof vesicovaginalfistula
apply traction to inflated catheter
To achieve hemostasisin myomectomy

C) COMPLICATIONS
Introduction of infection
Catheter fever
Reflex anuria
False passage
Urethral strictures after repeated
catheterisation

IUCD removal hook :
Features-handle with angulationand tip has
hook and sharp point of hook is directed
towards angled side of instrument.
Use :
1.Removal of embedded IUD from uterine
cavity
2.Removal tubal prosthesis from uterine cavity
Complications
Pain and perforation

NOTE
Angulationand hook at tip

Novak’s endometrial biopsy curette:
Features : tip with sharp serrations and proximal
end has Leurlock hub and a stillatesto
remove endometrial strip and to clean the
curette.
Uses :
Endometrial biopsy.

Colwin’scannula:
Features : spiral conical tip with proximal end
having Leurlock hub with stillete.
Uses : used only in multiparouscervix with
patulous os.
1.Hystero-salpingography
2.Chromo-pertubationtest in laparoscopy
3.Hydrotubation

Uterine manipulator (Hulkamanupulatorfor
normal sized uterus)
Feature : it is a combination of vulsellumand
uterine sound.
Uses : manupulateuterus during-
1.Laparoscopic tubal ligation
2.Mini laparotomytubal ligation
3.Diagnostic laparoscopy

Sampling the cervix using an
endocervicalbrush
Samplingthe cervix. Note pointed
end of spatula in cervical os
An Ayreand an Aylesburyspatula

Preparation of a cervical smear. Note
coplinjar containing fixative is
immediately to hand to prevent air
drying
A range of smear taking devices:
Endocervicalbrushes, wooden
spatulae, and broom

Collection of specimens
Specimens can be obtained in three ways
•Scraping the ectocervixwitha modified spatula (the Ayrespatula or a
variation of it) for obtaining material for preparing conventional cervical
smears
•an endocervicalbrush.
•Using a broom like device which samples both endoand ectocervix.
Steps are essential to ensure the Pap test is performed correctly
•A speculum must be inserted into vagina to locate cervical os.
•The sampling device(s) used should be selected according to the shape and
size of the cervixand the location of the squamocolumnarjunction. An Ayre
spatula is suitable for sampling the cervix in a parouswoman ; however a
spatula and brush may be needed in a post menopausal woman where the
squamocolumnarjunction lies within the endocervicalcanal.
•The pointed end of the spatula should beinserted into the cervical osin a
nulliparouscervix and the rounded end of the spatula inserted into
thepatulous osof a parouswoman. Thedevice should berotated 360
degrees to remove the cells fromthe region of the transformation zone,
squamocolumnarjunction and endocervicalcanal.

•The material on the spatula or brush must be
transferred immediately to a glass slide which has been
previously labeled with the patient’s name and
registration number.
•The glass slide fixed immediately with an appropriate
fixative (95%alcohol) and the slides transported to
thecytology laboratory in a containerfor processing
together with the corresponding cytology request
form.
•Samples taken for Liquid Based Cytology should be
processed strictly in accordance with the
manufacturers instructions. After sampling the
cervix,the tip of the sampling device should be broken
off into the transport medium in the container
provided which should then be transported to the
laboratory for processing if the Surepathmethod is
being used. However if the Thinprepmethod is being
used it is of the upmost importance that the tip of the
sampling device is notincluded in the container

•Sampling the cervix using an endocervicalbrush
Samplingthe cervix. Note pointed end of spatula in
cervical osAn Ayreand an Aylesburyspatula
•Preparation of a cervical smear. Note coplinjar containing
fixative is immediately to hand to prevent air drying A
range of smear taking devices: Endocervicalbrushes,
wooden spatulae, and broom
Fixation of Pap smears
Properfixation isan essential step in the preparation of
cervical smears. It ensures that the cells arewell stained
and clearly displayed for microscopic analysis and
preserved for immediate and future review. Fixation can be
achieved by complete immersion of the slide in one of
alcohol fixatives listed below for 15-20 minutes after
which the slide can be removed from the fixative and
transported to the laboratory for staining.
Alternatively,fixationcan also be achieved by spray
fixation. Spray fixative consist of an alcohol base and
carbowaxthat provides a thin protective waxy coat over
the slide. The carbowaxmust be removed by immersion in
alcoholbefore staining

A satisfactory fixative hasto meet several requirements.
1. It should penetrate the cell rapidly so that detailed cell
morphologyis maintained.
2. Cell shrinkage should be minimal and uniform so that
morphological distortions do not occur .
3. It should allow permeability of dyes across the cell boundaries
and appropriate for the staining method used
4. It should permit cell adhesion to the glassmicroscope slide
5. It should bebactericidal, non toxic and permanent..
The following fixatives aresuitable for the fixation ofcervical smears
which are to be stained by the Papanicolaoumethod.
•95% ethanol (for optimal fixation)
•80% isopropanol
•95% denatured alcohol (90 parts 95% ehanol, five parts absolute
methanol andfive parts absolute isopropanol)
•Reagent grade alcohol (absolute methanol, 80%isopropanol,90%
acetone)
Fixation must be immediate. The smear must not be allowed to dry
before fixation

Classification
Suture material
Absorbable
Non absorbableAbsorbable
Synthetic
Natural
Non absorbable

Characteristics of an ideal suture material :
1.Its use should be possible in any operation the only
variable being its diameter as determined by its tensile
strength
2.It should allow easy and comfortable handling
3.Tissue reaction stimulator should be minimal and should
not be favorable to bacterial growth
4.The breaking strength should be high in small caliber
5.The knot should hold securely without fraying or cutting
6.Material should not shrink in tissues
7.Should have uniform physical property
8.Its material should be non electrolytic, non capillary, non
allergic and non carcinogenic
9.Should be sterile
10.Should be absorbed with minimal tissue reaction after it
has served its purpose

Catgut
•Made up of ribbons of sheep or beef intestinal
submucosa(collagen) spun into strands of varying size from 7-
0 to 3.
•it is absorbed by tissue or cellular proteases.
•Knot configuration 1*2
Features Plain catgut Chromic catgut
Constitution Not treatedwith chromium salt Treated with 20% chromium salt inwater
with 5 parts of glycerin for 1 to 96
hours.(true chromatisation/surface
chromatisation)
Absorption 7 days 4-6 weeks
Advantages Ease of handling Ease of handling and knot security
Disadvantages Early loss of tensile strength and
weak knot strength
Variability in absorption
Uses Ligating blood vessles&
subcutaneuostissue
Uterine,peritoneal and subcutaneous
tissue closure, tubal ligation

POLYGALACTIN (910)/ VICRYL
Braided multifilament, coated with copolymer of lactide&
glycolide
Violet coloured, Sizes from 9-0 to 3
Knot configuration 2+1+1+1
Suture is absorbrdby hydrolysis & non inflammatory cell
enzymatic degradation.
80 % tensile strength is lost by 21 days, absorption is minimal for
40 days & complete in 56-70 days
TYPES
1) Coated vicryl-coated with calcium stearateit permits precise knot
placement & smooth tie down
2) Vicrylrapide–High initial tensile strenghtabsorbed rapidly in 14
days
Absorbed completely in 6 wks
Ideal for suturing episiotomy
3) Vicrylplus –Has coating made up of tricosanhaving antimicrobial
properties
Uses: uterine closure , to suture rectus sheath.

Polypropylene suture
Monofilament, composed of linear hydrocarbon
polymer
Non absorbable
Non capillary
Better knot security
High tensile strength least tissue reactivity can be
used in presence of infection.
2+1+1+1 knot configuration.
Use
for fascialclosure in patients with high risk for
dehiscence
Fixation of prolenemesh

Surgical silk
Made up of twisted or braided fibers of raw protein thread
spun by silkworm larva.
Though classified as non absorbable, tensile strength lost in
1 yr and totally absorbed in 2 yrs. (very slowly absorbing
suture)
Untreated silk has capillary action but
treated(trupermanizing/surgical silk) is non capillary/
serum proof.
Twisted silk : non absorbable coating of tanned gelatin/ other
protein substance which prevents growth of tissue.
Virgin : several silk filaments are
twisted together to form fragile strand
of 8-0, 9-0 used in microsurgery.
Uses : fixation of drain

Linen
Made from long flax fibrestwisted in strands
Size : 4-0 to 2.
Tensile strength is inferior
Diameter is not uniform
Use : ligatingbleeders, safety suture for stumps.

Magnesium sulphate
Class–Anticonvulsant and sedative
Category A
Mechanism of action-
1.Reduces end plate sensitivity to acetyl choline
2.Reduces acetyl cholinerelease
3.Blocks Ca++ channels
4.Direct depressant action on uterine muscle
Uses-
•local-anti inflammatory.
•Parenteral-drug of choice in prevention and treatment of siezurein pre-
eclampsiaand eclampsia, tocolyticin preterm labour.
Contra-indications-myestheniagravis, impaired renal function.
Side effects-
•Maternal : respiratory depression, muscular paresis, flushing, perspiration,
headache, rarely pulmonary edema.
•Fetal-lethargy, hypotonic, rarely respiratory depression.
Anti-dote: inj. Calcium gluconate10% 10 ml iv

Mechanism : Mgso4
Neuromuscular
Conduction
slowed
Neuronal
Burst
Firing
Abort
Convulsion
Ach secretion by
motor nerve end
Prevent
Convulsion
Sensitivity of end
plate to Ach
Prevent
Convulsion
N-Methyl D-
Aspartate
Receptors
Blocked
Ca
++
entry
blocked
Abort
Convulsion

Alternative regimens for
magnesium sulphate
Regimen Loading Dose Maintenance
dose
Total dose
Pritchard 4 gm IVover 3-
5 min. followed
by 10 gm IM
deep.
5gm IM4 hrly
in alternate
buttock. 30 gmsin
preeclampsia,
Continued upto
24 hrs after
last convulsion
or delivery
whichever is
later.
Zuspan 4 gm IV over
15-20 min.
1-2 gm / hr IV
infusion.
Low Dose
Regimen
4 gm IVover
period of 3-5
min.
2 gm I.M /
diluted IV 3
hourly.

IV/IM Mgso4
No evidencefrom the
Collaborative Trial of any
differencebetween the
intramuscular and
intravenous regimens.
However intramuscular
injections are painful and are
complicated by local abscess
formation in 0.5% of cases.
Whenmagnesiumsulfateisadmin
IV,theonsetofactionis
immediateandthedurationof
actionisabout30min.
FollowingIMadminofthedrug,
theonsetofactionoccursin
about1hrandthedurationof
actionis3-4hr.
Onset–IV<IM
DurationOfAction–IV<IM

Monitoring ---–
•The maintenance dose of Magnesium Sulphateis
given only after assuring that:
•Patellar reflex is present
•Respiration not depressed. ( RR > 16/min)
•Urine output during previous 4 h-exceeded 100 mL.
(25ml/hr)

Labetalol
Class-anti-hypertensive
Category C
Mechanism of action-–β1+β2+ α1 adrenergic
blocker with weak β2 agonist(5 times more
capable of locking B than α)
Uses-hypertension in pregnancy, hypertensive
crisis.
Contra-indications-hepatic disorders, asthma,
CCF.
Side effects -rash and liver damage, fetal
hypoglycemia.
T1/2-4-6 hrs
Regime–
•Orally 100mg tdsupto800 mg daily
•Intravenous starting with 20 mg iv bolus if
no response in 10 mins40 mg iv bolus then 80 mg every 10
minswith total dose of 220 mg per episode.

Nifedepine
Class–dihydropyridinecalcium channel blocker
Category C
Mechanism of action-
voltage-gated calcium channel blockage in
cardiac muscle and blood vessels(vasodilatation)
Uses-
hypertension, angina pectoris, prevention of
preterm labour
Precausion-use with MgSO4 can be hazardous
Side effects-flushing, hypotension, headache, tachycardia,
inhibition of labour.
T1/2–2 to 5 hrs
Regime
•5-20 mg bd/tdsmax dose 200mg
•prevention of preterm labour-20-30 mg stat and 10-20 mg
every 6 hrly.

Alpha methyl dopa
Class –anti hypertensive
Category B
Mechanism of action-
•Stimulates αreceptors and decreases
sympathetic outflow from CNS
•Decreases peripheral vascular resistance
Uses-pregnancy induced hypertension
Max effect in 4 hrs, total duration of action is 8 hrs
Contra-indications-hepatic disorders, psychiatric
disorders, CCF
Side effects-postural hypotension, sedation,
lethrgy, reduced mental capacity, dryness of
mouth.
Regime 250 mg tdsmax dose 2 gms

Phenobarbitone
Class –anti convulsant
Mechanism of action-acts by raising
threshold for electric stimulation of
motor cortex.(produces all degree of depression)
Uses-
•Epilepsy
•Sedation for threatened abortion/during preoperative
preparation
•Neonatal jaundice
Side effects:
Maternal : excitement, nausea, vomiting, megaloblastic
aneamia, habituation.
Fetal : neonatal depression, coagulopathy, teratogenisity.
Regime : 15-30 mg 3-4 times a day

Oxytocin
(invented by du Vigneaudin 1953 and received noble
prize in chemisteryin 1955)
Category C
Class–uterine stimulant
Mechanism of action-
1.Acts through receptors and voltage mediated C++ channels
2.Stimulates amniotic and decidualPG production
Uses-
1.Induction and augmentation of labour
2.Uterine inertia
3.Prevention and treatment PPH
4.Breast engorgement
5.Oxytocinchallenge test

Contra-indications-
Side effects
•Maternal: uterine hyper stimulation, uterine rupture, water intoxication,
hypotension
•fetal : fetal distress
Plasma half life -3-4 mins, duration of action 20 mins
Regime : High dose(4-6 mIU/min),low dose(1-4 mIU/min)
Oxytocinescalating doses-(Anderson’s logarithmic method of titration)-start
in a dose of 4 U in 500ml of RL and double the dose with every pint i.e. 8-
16-32 and so on uptomax. of 100U.
Pregnancy Labour Any time
Grand multiparaAs in pregnancyHypovolemicstate
Contracted pelvisObstructed labourCardiac disease
H/O CS or
hysterotomy
Inco-ordinate
uterine contraction
MalpresentationFetal distress

Oxitocinregimen:
Oxitocin2.5 U in 500 ml NS started at 10 drops/
min(2 –2.5 mU/min), dose is raised every 30
minstill 4 contractions per 10mins each
lasting for > 40 seconds are obtained.
Set 1 ml = 20 drops Set 1 ml= 15 drops
10 drops/min = 2.5 mu/min 10 drops/min = 3.4 mu/min
20 drops/min = 5 mu/min 20 drops/min = 6.6 mu/min
30 drops/min = 7.5 mu/min 30 drops/min = 9.9 mu/min
40 drops/min = 10 mu/min 40 drops/min = 13.2 mu/min
50 drops/min = 12.5 mu/min

Methyl Ergometrine
Class-Uterine stimulant
Category C
Mechanism of action-
•Blood vessel constrictor and smooth muscle agonist
•Acts directly on the smooth muscle of the uterus and
increases the tone, rate, and amplitude of rhythmic
contractions
Onset of action : Oral -10 min, im-4-7 mins, iv-40 sec.
Uses-
•routine management after delivery of the placenta; PPH;
•Subinvolution
•most commonly used to prevent or control excessive bleeding
•Uterine contractions to aid in expulsion of retained products
of conception
•Incomplete abortion

Side effects
Cholinergic effects such as nausea, vomiting, and diarrhea,
Cramping, dizziness, Pulmonary hypertension, Coronary
artery vasoconstriction, Severe systemic hypertension
(especially in patients with preeclampsia), Convulsions.
Contraindications-hypertension, toxemia of pregnancy; and
hypersensitivity, before second twin is born, heart disease,
Rhnegative status, vascular disease.
Half life –1-2 hrs
Regime-
parenteral: 1mL(0.2 mg) after delivery of the anterior
shoulder, after delivery of the placenta, or during the
puerperium. May be repeated as required, at intervals of 2-
4 hours.
Oral : One tablet, 0.2 mg, 3 or 4 times daily in the
puerperiumfor a maximum of 1 week

Misoprost(PGE1)
Class–uterine stimulant
Category X
Mechanism of action-
•Binds to myometrialcells to cause strong myometrial
contractions.
•Cervical ripening with softening and dilatation of cervix
Uses-
Abortion, induction and augmentation of labour, prevention of
PPH,
Cervical priming before gynecological procedures like D n C and
hysteroscopy.
[vaginal route-action is slow and sustained
Oral-action is rapid and short duration]

COMPLICATIONS :
› Uterine hyperstimulation.
› Uterine rupture.
› Fetal heart rate abnormalities.
› Amniotic fluid embolism.
› Retained placenta.
› Tachysystole, meconiumpassage
› Meconiumaspiration syndrome.
T1/2-1 –2 mins
Antidote-0.25 mg terbutalinesc

Clinical situations and dose
› For MTP use :
Isttrimester-400mcg every 4 hrly( max.1600mcg )
IIndtrimester-400mcg every 4 hrly
› For pre induction
Cx ripening use : 25-50 mcg 4-6 hourly.(max
dose 150 mcg)
› For IUD –13-24 wks 200mcg/4hrly
late-100 mcg/ 6-12 hrs
› For viable pregnancy : 25 mcg intravaginal4 hrly
maximum doses 150 mcg
› For PPH : Prophylaxis 600 mcg / rectal
treatment 1000 mcg / rectal

Dinoprostone
Class–prostaglandin
Mechanism of action-
•Binds to myometrialcells to cause strong myometrial
contractions.
•Cervical ripening with softening and dilatation of cervix
Uses-induction of labour
Contra-indications-
•For induction of labourin women with ---
› Scarred Uterus (pre.LSCSor Uterine surgery)
› Grand multiparae.
•Hypersensitivity
•Asthma
Side effects-nausea, vomiting, diarrhea, vaginal irritation,
hyperstimulationsyndrome.
T1/2-contraction starts within 1 hrs & peak at 4 hr.
Regime-0.5 mg(3ml) over 6 hrs with 3 doses in 24 hrs.
Antidote-0.25 mg terbutalinesc

Carboprost
Class–prostaglandin
Mechanism of action-
•Binds to myometrialcells to cause strong myometrialcontractions.
•Cervical ripening with softening and dilatation of cervix
Uses-
•prophylaxis and treatment of PPH,
•IIndtrimester MTP
•Isttrimester MTP for softening of cervix
Contra-indications-
•For induction of labourin women with ---
› Scarred Uterus (pre. LSCS or Uterine surgery)
› Grand multiparae.
•Hypersensitivity
•Asthma
Side effects-nausea, vomiting, diarrhea, vaginal irritation, rupture of
uterus
Regime-250 mcg imevery 20 minstill bleeding stops or max 8
ampoules.

Mefipristone
Class –Anti-progestine
Mechanism of action-(Competetiveanti-progestationaland anti-
glucocorticoid.)
•Attenuate mid-cycle Gnsurge
•Prevents secretorychange by progesterone
•Stimulates uterine contractions
•Blocks decidualisation
Uses-
•Termination of pregnancy upto7 weeks
•Cervical ripening
•Post coital contraceptive and once a month contraceptive
•Inaductionof labour

Contra-indications -
Side effects-Nausea, Vomiting, Diarrhea,
Headache, dizziness, Chills or hot flushes,
Shivering, Fatigue
T1/2-20-36 hrs
Regime –200 gm single dose

Ethacrydinelactate
Class–uterine stimulant
Mechanism of action-
Stripping of membranes with liberation of PGs
Uses-
•antiseptic in solutions of 0.1%.
•second trimester abortion. Up to 150 ml of a 0.1% solution is
instilled extra-amnioticallyusing a foleyscatheter
Contra-indications-hypersensitivity
Side effects-anaphylactic reaction
Hypersensitivity, prolonged use delays wound healing
Regime10 ml/gestational wk of 0.1% solution (max:
200 ml),

Iron Sucrose
Category B
[iron dextran(inferon), iron sorbitrate(jectofer),iron
dextrin(maltofer),sodium ferric gluconatecomplex,
iron saccharate, iron sucrose]
Composition : 100mg/5ml
Indications :
-Iron deficiency
•Poor compliance to oral iron
•Inadequate absorption of oral iron
•Lack of response to oral iron
-Anemia of those patients suffering from chronic
haemodialysis.

•Contraindications : Hypersensitivity, Iron
overload
•Safety Profile :
•Caution required in pregnancy, safety has not
been established to administer in nursing mother,
children and geriatric.
•Adverse Effects :
•Hypotension, anaphylactoidreactions,
musculoskeletal pain, diarrhoea, nausea
vomiting, abdominal pain, pruritus, elevated liver
enzymes, pain at injection site.
•Dosage :
•100mg (5ml) one to three times per week.
•Expected rise in Hb-0.7-1 gms% /week

Oral iron(ferrous sulphate, ferrous gluconate,
ferrous fumarate, ferrous ascorbate, sodium
ferridatate, iron hydroxide polymaltose, ferric
amm.Citrate, carbonyl iron)
Class–Heamatinics
Uses-iron defficiency
aneamiaprophylaxis and treatment,
megaloblasticaneamia
Contra-indications-
Side effects-epigastricpain, nausea, vomiting,
staining of teeth, metallic taste,bloating,
constipation.
Regime –200mg(60mg elemental iron) tds

Folic acid
Classheamatinics
Category A
Uses-megaloblasticaneamiatreatment and
prophylaxis, in methotraxatetoxicity,
phenytointoxicity, prevention of abruption.
Side effects-nontoxic
Folinicacid-used for prevention and treatment
of methotraxatetoxicity within 3 hrs of
administration.
Regime–therapeutic-2-5 mg/day
prophylactic-0.5 mg/day

Terbutaline
Class –tocolytic
Category B
Mechanism of action-β2 adrenergic stimulant(↓
intracellular Ca++ →inhibits MLCK→inhibitsinteraction
of actinand myosin → smooth ms relaxation)
Uses-
•prevention of preterm labourfor atleast48 hrs for
action of corticosteroids
•Antidote for prostaglandin induced uterine
hyperstimulation
Side effects-
Maternal-headache, palpitation, tachycardia, pulmonary
edema, hypotension.
Fetal-tachycardia, heart failure, IUFD.
Regime 0.25 mg SC every 3-4 hrly.

Ritodrine
Class –tocolytic
Mechanism of action-β2 adrenergic stimulant(↓ intracellular
Ca++ →inhibits MLCK→inhibitsinteraction of actinand
myosin → smooth ms relaxation)
Uses-
•prevention of pretemlabour
•External cephalic version
Side effects
Maternal: tachycardia, hypotension, palpitation,
hyperglycemia, hypokaleamia, pulmonary edema.
Fetal : hyperkalemia, hypoglycemia, hypotension, respiratory
distress syndrome.
Regime: tablet 10 mg, 10mg/ml
0.05-0.35 mg/min for 12 hrs increased by 50 mcg/min
every 10 mins, orals started ½ hr before discontinuation of
iv drip. Then tablet 2 hrlyfor first day and then 4-6 hrlyon
subsequent days.

Isoxsuprine
Class –Tocolytic
Mechanism of action:β2 adrenergic stimulant(↓ intracellular Ca++
→inhibits MLCK→inhibitsinteraction of actinand myosin → smooth
ms relaxation)
Uses-
•prevention of pretemlabour
•External cephalic version
Contra-indications-
Chronic cardiac disease, hyperdynamic
circulation, chorioamionitis, fetal demise, fetal malformation.
Side effects:
Maternal: tachycardia, hypotension, palpitation, hyperglycemia,
hypokaleamia, pulmonary edema.
Fetal : hyperkalemia, hypoglycemia, hypotension, respiratory distress
syndrome.
Plasma half life: 1.5-3 hrs
Regime : 2 cc imevery 8 hrly
10 mg bd/tds

Maternal Corticosteroids
(Betamethasoneand Dexamethasone)
Betamethasone2 doses 12 mg IM 24 hrs apart
Dexamethasone4 mg IM every 6 hrs total 4 doses
Repeat or booster dose are not needed
Relative contraindication
-may be used with caution in c/o severe preeclampsia
-impaired GTT
-severe arenalinssufficiecybetween 28-34 weeks
Dexaalso used in HELLP syndrome
CORTICOSTEROIDS-
Indicated between 28-34 weeks
Contraindication-1) diabetic mother
2)chorioamniotis

Cefotaxim
Class–cephalosporine(third generation-parenteral)
Category B
Mechanism of action-inhibits bacterial cell wall
synthesis
Uses-
1.respiratory, urinary and soft tissue infection
2.Surgical prophylaxis
3.Infections like meningitis, typhoid, gonorrhea, hospital
acquired infections
Side effects
Thromboplebitis, diarrhea, hypersensitivity.
T1/2-1 hr but longer for deacetylatedmetabolite
Regime–1-2 gmsiv 8-12hrly

Metronidazol
Category B
Class –tissue amoebicide(nitroimidazole)
Mechanism of action-nitro group disrupts pyruvate
pathway energy metabolism in anearobes
Uses-amoebiasis, giardiasis, Trichomonasvaginalis,
anearobicbacterial infection.
Contra-indications-in neurological diseases, blood
discrasias, Isttrimester pregnancy,chronic
alcoholism.
Side effects-anorexia, nausea, vomiting, metallic
taste, abdominal cramps.
T1/2-8 hrs
Regime –orally 400 mg tds
parenterally-500 mg/100 ml iv suspension tds

Ciprofloxacin
Class –Flouroquinolones
Category C
Mechanism of action-damages bacterial DNA→ damaged
DNA digested by endonuclease→celllysis
Uses-UTI, gynecological and wound infection, gonorrhea,
bacterial gastro enteritis, typhoid, MDR-TB.
Contra-indications-pregnancy and lactation.
Side effects-
nausea, vomiting, bad taste, headache, anxiety, skin
hypersensitivity.
T1/2-3-5 hrs
Regime-oral:500 mg bd
iv: 200 mg bd

Clotrimazole
Class –anti fungal(azole)
Category B
Mechanism of action-inhibits cytochromeP450
→ cascade of membrane instability
Side effects-local irritation
Uses-vaginal candiasis
Regime –1% lotion/cream
100 mg vaginal tablet

Clindamycin
Class –Lincosamideantibiotic
Category B
Mechanism of action-inhibits protein synthesis
Uses-Anearobicand mixed
infection(abdominal/lung/pelvic abcsess),
bacterial vaginosis.
Contra-indications-
Side effects-urticaria, abdominal pain, diarrhea
and psuedo-membranous enterocolitis
Regime –150-300 mg qidorally or
200-600mg iv 8 hrly

Fluconazole
Class –tri-azoleanti-fungal
Category C
Mechanism of action-inhibits cytochromeP450
→ cascade of membrane instability
Uses-cryptococcalmeningitis, systemic/ local
candidiasis, recurrent candiasis.
Side effects-nausea, vomiting, abdominal pain,
rash.
T1/2-25-30 hrs
Regime-150 mg single dose for vaginal candidiasis

Nevirapin
Class –anti retroviral[non-nucleoside reverse transcriptase
inhibitor (NNRTI)]
Category C
Mechanism of action-inhibitsnon-nucleoside reverse
transcriptase anessential viral enzyme which transcribes
viral RNA into DNA. Active only against HIV 1 infection
Uses-
•triple combination therapy has been shown to suppress viral load
effectively in HIV-AIDS
•Prevention of vertical transmission-single dose of nevirapinegiven
to both mother and child reduced the rate of HIV transmission by
almost 50%
Contra-indications-
Side effects-
•mild or moderate rash, Stevens-Johnson syndrome, toxic
epidermal necrolysisand hypersensitivity
•severe or life-threatening liver toxicity.

Dosing of Nevirapine
Adult
Immediate-release (IR) tablet or oral suspension: 200 mg
QD for 14 days, then 200 mg BID
Extended-release (XR) tablet:
•400 mg QD If initiating treatment with nevirapine: start
with IR tablet, 200 mg QD for 14 days; then change to
XR tablet, 400 mg QD If switching from nevirapineIR
formulation (200 mg BID) to XR formulation: start XR
tablet, 400 mg QD (without lead-in dosage adjustment)
•PediatricAge 15 days-adolescence 150 mg/m
2
QD for
the first 14 days, then 150 mg/m
2
BID; maximum total
daily dose: 400 mg
•Prevention of Mother-to-Child Transmissionsingle
dose 200 mg in active labour

Aspirin
Class –NSAID
Category if < 150 mg/day-C,
in standard dose D
Mechanism of action-nonselective inhibition of
COX-2 enzyme
Uses-analgesic, antipyretic, post MI/ stroke, pre-
eclampsia.
Contra-indications-peptic ulcer, liver disease,
diabetic.
Side effects –nausea, vomiting, epigastricpain,
hypersensitivity.
Regime: low dose -75 mg od.

Heparin
Class –anti coagulant
Mechanism of action-
Acts indirectly by activating plasma antithrobinIII →
binds and inactivates clotting factors (Xaand IIa)
of intrinsic and common pathway of coagulation
Contra-indications-bleeding disorders, severe
hypertension, threatened abortion, piles, GI
ulcers, sub acute bacterial endocarditis.
Side effects-bleeding, thrombocytopenia, alopecia,
osteoporosis, hypersensitivity.
Regime-low dose 5000 U sc every 8 hrly.

Low molecular weight heparin
Class –anticoagulant
Category C
Mechanism of action-selectively inhibit factor Xaand not
IIa.
Uses-
Prophylaxis and treatment of DVT
Unstable angina
Maintain patency of indwelling canulaeand shunts
In treatment of APLA syndrome
Advantages over unfractionatedheparin
Better subcutaneous Bioavailability, longer t 1/2, aPTT
and clotting time not increased.
Regime-pamparin: 0.6 ml sc OD.
Antidote-protaminsulphate1 mg for every 100 U of
heparin

Methotraxate
Class –anti-metabolite
Category X
Mechanism of action-inhibits dihydrofolate
reductase→ blocks DNA synthesis
Uses-invassivemole, choriocarcinoma,
leukemias, rheumatoid arthritis, psoriasis.
Side effects-: ulcerative stomatitis, low white blood cell
count and thus predisposition to infection, nausea, abdominal
pain, fatigue, fever, dizziness and rarely pulmonary fibrosis
teratogenic, bone marrow depression, renal tubular necrosis.
Regime –1 mg/kg
100 mg/ m2 body sufacearea

Metformin
Class –Oral hypoglyceamic(Biguanides)
Category B
Mechanism of action-
•Suppress hepatic gluconeogenesisand glucose output from
liver
•Enhances insulin mediated glucose disposal in muscle and fat
•Retards glucose absorption in GIT
•Enhances peripheral glucose utilization
Contra-indications-hypersensitivity, hypotension,
CVS, RS, hepatic and renal disturbance.
Side effects-abdominal pain, anorexia, metallic
taste, tiredness, lactic acidosis.
Regime –0.5 –2.5 gms, 2-3 doses.

Cabergoline
Class –D2 agonist
Category B
Mechanism of action-long-acting dopamine D2-receptor agonist
(decreases prolactinesecreationby activating dopaminergic
receptors)
Uses-
prevention of lactation
hyperprolactanemia
Contraindication
•Hypersensitivity
•Severely impaired liver function or cholestasis
•Cautions: severe cardiovascular disease, Raynaud'sdisease,
gastroduodenalulcers, active gastrointestinal bleeding,
hypotension.
Side effects-Nausea, vomiting, stomach upset, constipation, dizziness,
lightheadedness or tiredness.
Regime –2.5 mg stat for breast supression

Tetanus vaccine
Class –Toxoids
Category C
Uses-
•Routine immunization of children and mothers
•After injury that might lead to intriductionof tetanus bacilli
Contra-indications-hypersensitivity
Side effects-local pain, erythema, induration,
fever chills, malaise.
Regime –0.5 ml single dose im.

Anti Rhimmunoglobuline
Class –vaccine
Category C
Mechanism of action-masks Rhantigen on fetal RBC,s
after fetomaternal bleed hence prevents maternal
sensitization
Uses-prevention and prophylaxis of post delivery or post
delivery Rhisoimmunisation
Contra-indications-hypersensitivity
Should be given with in 72 hrs of delivery
T1/2: 22-28 days but action lasts till 42 days
Regime-300 mcg post delivery
150 mcg post abortion
(10mcg/ ml of whole blood or 20 mcg/ml of PRC feto-
maternal bleed)

Tranexemicacid
Class–anti fibrinolytic
Category B
Mechanism of action-binds to lysin
binding site on plasminogenand
prevents its combination with fibrin.
Uses-
•DUB
•Cu-t menorrhagia
Side effects-nausea, diarrhea, headache, giddiness,
thrombophlebitis.
Contraindications-severe renal insuficiency,
hematuria.
Regime–10-15 mg/ kg 2-3 times a day

Clomiphenecitrate
Class–anti-estrogenic
Category X
Mechanism of action-induces gonadotropinsecreationby blocking
estrogenic feedback inhibition.
Uses-
•sterility due to failure of ovulation
•aid in-vitro fertilization,
•PCOD
•AnovulatoryDUB
•oligospermia.
Contra-indications-ovarian cyst, ovarian failure, hepatic dysfunctions and
occurrence of visual symptoms.
Side effects-poly-cystic ovaries, multiple gestation, hot flush, risk of ovarian
tumor increases, ovarian hyper stimulation syndrome
Clomipheneresistance-absent ovulation with 100 mg clomiphenefor 5 days
in 3 cycles
Clomiphenefailure-absence of pregnancy even after ovulation with CC
T1/2-6 days
Regime–50 mg once a day for 5 days starting from 5
th
day of cycle.(max
200mg /day.)

Drotaverine
Class –antispasmodic
Mechanism of action-selective inhibitor of
phosphodiesterase4, and has no anti-
cholinergic activity
Uses-
•treating renal colic.
•It has also been studied in accelerating labor by
speeding up cervical dilation
Contra-indications-severe hepatic or renal failure
hypersensitivity
Side effects-nausea, vomiting, headache, allergic reaction
Regime (1 amp contains 20 mg)
Acute renal colic-40-80 mg iv

Micronisedprogesteron
Ind-lutealphase support
-threatened abortion
-preterm labour
-secondary amenorrhea
-DUB
Dose-100mg,200mg,300mg,400mg
Route-Oral,Injectable,Vaginal
Mechanism of action-
-preparation of endometriumfor blastocystimplantation
-promotes follicular cyst development
-acts as immune system mainly by affecting cytokine synthesis
and function of NK cell
-decresesuterine contractility
-helps in development of fetal brain by multimodal effect
-prevents preterm labour

ESTROGEN
Female sexual hormone & growth hormone for mullerian
system
SYNTHESIS OF ESTROGEN
Steroidal hormone derived from lipid precursor
cholesterol in graffianfollicle, corpus luteum& placenta
Androstenedione Estrone(E1) Estriol(E3)
Ring A aromatisation
Testosterone Estradiol(E2)
A)NATURAL ESTROGENS
Etsradiol( 17β-Etradiol/ E2)is the major estrogen secreted
by ovary
Estrone(E1)
Estriol(E3)
Principle estrogen before menopause –Estradiol, after
menopause –Estrone

EstradiolEstroneEstriolCH
3
OH
OH CH
3
OH
O CH
3
OH
OH
OH

B) SYNTHETIC ESTROGENS
Natural estrogens are inactive orally & have shorter
duration of action due to rapid metabolism in liver
To overcome these shortcomings synthetic estrogens
have been introduced
However currently introduced micronisedestradiol
preparations are orally active
a) CONJUGATED STEROIDAL ESTROGENS
Estronesulphate, Estradiolvalerate, Estradiolbenzoate,
Estradiolsuccinateor hemisuccinate
b) NON CONJUGATED SYNTHETIC ESTROGENS
17α -Ethinyletsradiol, Mestranol
c) NON STEROIDAL
Diethylstilbesterol( oral), Hexosterol, Dienesterol
(topical)

d) ESTROGEN ANALOGOUES
Clomiphene, Tamoxiphene, Raloxiphene, Ormiloxiphene,
Chlorotrianesene
MECHANISM OF ACTION
2 types of receptors ERα & ERβ
Most tissues express both subtypes but ERα
predominates in uterus, vagina, breast,
hypothalamous & blood vessels while ERβ
predominates in prostate gland
Binding of agonist to receptor causes dimerisation of
receptor & its interaction with ‘Estrogen Responsive
Elements’(EREs) of target genes
Gene transcription is promoted through certain
coactivator proteins
In case of antagonist binding the receptor assumes a
different conformation & interacts with corepressor
proteins inhibiting gene transcription

PHYSIOLOGICAL ACTIONS
Stimulates development of vagina, uterus, breasts
Development of secondary sexual characters
Redisributionof fat to hips & breasts
Responsible for accelerated growth phase &
epiphysealclosure of long bones at puberty
Maintainance of normal structure of skin & blood
vessels
Stimulates hepatic synthesis of many proteins like
transcortin, thyroxine binding globulin, sex hormone
binding protein, transferrin, renin substrate, fibrinigen
causing increased circulating levels of thyroxin,
estrogen, testosterone, iron & copper
Decrease in resorption of bone by antagonising
effects of PTH

Increased coagulability of blood by increasing
concentrations of factors II, VII, IX, X & increased
plasminogen & decreased platelet adhesiveness
Increase HDL cholesterol & triglycerides & decrease
total & LDL cholesterol
Facilitate movement of fluid from the plasma to the
extravascular space
USES
1)HRT-
Estradiol the safest estrogen
If osteoporosis is a risk best treated with tibolone
Estradiol if necessary may be considered in doses 1
mg/day
If cardiovascular risk is predominant tibolone is most
suited ,
Estradiol if necessary may be considered in doses 1
mg/day

For those with risk of of breast & endometrial cancer
tibolone is best , estradiol is better avoided
Those with vasomotor symptoms & neuroendocrine
deficits estradiol is best
Those at risk of venous thromboembolism & hot
flushes should avoid raloxiphene
Oophorectomised subjects should be on estradiol
from immediate postoperative period & may be
shifted to tibolone after few months
2) Oral contraceptive pills
Estrogen of choice is 17α ethinyl estradiol
Usual dose range from 50mg to 10 mcg
Dose of 20-30 mcg has been found to be most
optimal in combination with progestin
3)Senile vaginitis
 Effective in both preventing & treating atrophic
vaginitis , topical preparations are commonly used

3) Delayed puberty in girls
4) Can also be used in acne, hirsuitism, palliative
treatement of carcinoma prostate
5) Tamoxiphene is the first choice hormonal therapy in of
breast cancer in both pre & post menopausal women
ADVERSE EFFECTS
Increased risk of endometrial carcinoma
Increased incidence of breast carcinoma
Increased incidence of gallstones & benign
hepatomas
Increased risk of thromboembolic phenomenon
Stilbesterol given to pregnant women cause increased
incidence of vaginal & cervical carcinoma in the
female offspring
Migraine & endometriosis may be worsoned

PROGESTINS
Progestin= favoring pregnancy
Steroidal hormone derived from cholesterol, secreted by
corpus luteumin early pregnancy & later by placenta
Progesterone is a 21 carbon compound ,is the natural
progestin
Progesterone means only good things to women &
doesn’t cause any harm
Unfortunately clinical usefulness is limited by poor
absorption from oral route
Orally active progestinsin clinical practice are micronized
progesterone, esters of progesterone & 19-norsteroid
progestinsCH
3
CH
3
CH
3
O
O

A)CLASSIFICATION
Progesterone derivatives
a)Derived from pregnanering
1.Micronised progesterone
Oral, transdermal, IM, vaginal & rectal applications
( Prometrium, Utrogestan, Crinon)
2. Derivatives of progesterone
Restroprogesterone dydrogesterone –oral application
(Duphastone)
3. Esters of progesterone
Pregnane steroids(21 carbon compounds)
Hydroxyprogesterone derivatives :
Medroxyprogesterone acetate oral& paprenteral
application (Provera, Farlutal)17α
hydroxyprogesterone 17-n-caproate (Proluton
injectable)

b) Progestins derived from androsten ring (19 carbon
compounds)
4. Androstene steroids
Testosterone derivatives: Ethisterone , Dimethisterone,
Danazol-oral application
c) Progestins derived from estrane ring
5. Estrane steroids (18 carbon compounds) 19 nor
testosterone derivatives
Norethisterone, Norethisterone acetate, Allylstrenoloral
application ( Orgametril, Pregmate, Lyndiol, gestin)
d) Progestins derived from gonane ring
6. Gonane steroids (19 carbon compounds)
Structural modification of estrane & ethyl group at
position 13
Norgestrel( primovular)

7. Newer gonane steroids (19 carbon compounds)
Structural modification of gonane & methylene group at
position 11
Desogestrel, Gestodene ,Norgestimate (Novelon,
Femilon)
MECHANISM OF ACTION
Unlike other steroid receptors Progetserone
receptors(PR) have limited distribution in body mostly
confined to female genital tract, breasts, pituitary &
CNS
PR exists in 2 isoforms PR A&B
After binding to progesterone it undergoes dimerisation
attaches to progesterone responsive element &
regulates transcription through coactivators
Natural progesteron is inactive orally, most of the
synthetic progestins are active orally

PHYSIOLOGICAL ACTIONS
Brings about secretorychanges in estrogen primed
endometrium
Brings about decidualchanges in endometrium
Converts watery cervical secretions into viscid scanty
secretion
Acting along with estrogen prepares mammary gland
for lactation
Weak inhibitor of Gnsecretion from pituitary
Causes rise in basal body temperature by 0.5 degree
centigrade
It also has respiratory stimulant & CNS depressant
effect

Progestin Indication
19 norsteroids
(norgestrel, desogestrel,norgestimate)
Contraception
19 norsteroids
(norethisterone, norethisteroneacetate)
Hemostaticprogestins(DUB)
Dydrogesterone
(short acting progesterone like)
LPD,PMS, DUB, endometrial protection,
menopause
Esters of progesterone
(medroxyprogesterone)
Long term contraception, endometrial
protection
Micronisedprogesterone LPD,PMS, DUB, endometrial protection,
menopause
19 norsteroids
(tibolone)
Menopausal support
Bone & CVS protection
USES

ADVERSE EFFECTS
Breast engorgement, headache, rise in
body temperature, esophageal reflux,
acne mood swings
Irregular bleeding & amenorrhoea
19 nor testosterone derivatives lower HDL
levels & may promote atherogenesis
Blood sugar levels may rise & diabetis
may be precipitated by long term use of
agents like levonorgestrel
If given in early pregnancy may cause
masculanisation of female foetus
Intramuscular injections are painful

This is a specimen of uterus along with cervix and bilateral
adnexalstructures. Fungatingcauliflower like growth arising
from cervix appears to be fragile suggestive of carcinoma
cervix.

Different Types of The Lesion
Clinical :
1) Exophytic;
2) Ulcerative and
3) Infiltrative.
Histopathological
1) Squamouscell carcinoma (85-90%);-Large cell
keratinizing, Large cell non keratinizing, Small cell
2) Adenocarcinoma(10-15%).
3) Adenosquamous
4) Sarcoma
5) Malignant melanoma
6)Nuroendocrineca

Risk Factors
1)Humanpapillomavirusinfectionin70-90%ofcases-
commontypes16,18,6,11,31,33,45
2)Coitusbeforeageof18,multipleandhighrisksex
parteners
3)Deliveryof1
st
babybefore2oyrs,multiparitywith
poorbirthspacing
4)Poorpersonalhygieneandlowsocioeconomicstatus
5)STDs,HIVinfection,HSV-2
6)Immunosupressedindividual
7)Smoking,alcohol
8)OCpillsandProgestogens

Symptoms
•Postcoital,intermenstrualandpost
menopausalbleeding
•Offensivevaginaldischarge,lowerpelvic
pain,referredpaintolegs,frequencyof
micturation,hematuria,tenesmus,rectal
bleeding

CIN
Itiscervicalintraepithelialneoplasiainwhichapart
orfullthicknessofstratifiedsquamous
epitheliumisreplacedbydysplasticcellsbut
basementmembraneisintact.
1)CIN1(Milddysplasia)-lower1/3ofepithelial
thickness
2)CIN2(Moderatedysplasia)-lower2/3rdof
epithelialthickness
3)CIN3(Severedysplasia/Carcinomainsitu)-entire
thicknessofepitheliumwithintactbasement
membrane

Preventive Measures
Primaryprevention
(a)Identifyinghighriskfactors
(i)Earlysexualintercourse;(ii)Earlyageoffirst
pregnancy;(iii)Toomanybirthsandtoo
frequentbirths;(iv)Poorlocalhygiene;(v)STD-
HPVandHSVtypeIIinfection.
(b)Secondaryprevention
(i)Screeningagainstcarcinomacervix:cytology,
HPVtesting,colposcopyandbiopsy
(ii)"Downstagingscreening"byWHO-intendsto
diagnosethediseaseearlyandtominimise
cancerdeath.

Stage I
Stage I is carcinoma strictly confined to the cervix; extension to the uterine corpus should
be disregarded. The diagnosis of both Stages IA1 and IA2 should be based on microscopic
examination of removed tissue, preferably a cone, which must include the entire lesion.
Stage IA: Invasive cancer identified only microscopically. Invasion is limited to measured
stromalinvasion with a maximum depth of 5 mm and no wider than
7 mm.
Stage IA1: Measured invasion of the stromano greater than 3 mm in depth and no wider
than 7 mm diameter.
Stage IA2: Measured invasion of stromagreater than 3 mm but no greater than 5 mm in
depth and no wider than 7 mm in diameter.
Stage IB: Clinical lesions confined to the cervix or preclinical lesions greater than Stage
IA. All gross lesions even with superficial invasion are Stage IB cancers.
Stage IB1: Clinical lesions no greater than 4 cm in size.
Stage IB2: Clinical lesions greater than 4 cm in size.
FIGO staging of carcinoma cervix

Stage II
Stage II is carcinoma that extends beyond the cervix, but does not extend into the pelvic
wall. The carcinoma involves the vagina, but not as far as the lower third.
Stage IIA: No obvious parametrialinvolvement. Involvement of up to the upper two thirds
of the vagina.
Stage IIB
: Obvious parametrialinvolvement, but not into the pelvic sidewall.
Stage III
Stage III is carcinoma that has extended into the pelvic sidewall. On rectal examination,
there is no cancer-free space between the tumourand the pelvic sidewall. The tumour
involves the lower third of the vagina. All cases with hydronephrosisor a non-functioning
kidney are Stage III cancers.
Stage IIIA: No extension into the pelvic sidewall but involvement of the lower third of the
vagina.
Stage IIIB: Extension into the pelvic sidewall or hydronephrosisor non-functioning kidney.
Stage IV
Stage IV is carcinoma that has extended beyond the true pelvis or has clinically involved
the mucosa of the bladder and/or rectum.
Stage IVA: Spread of the tumourinto adjacent pelvic organs.
Stage IVB: Spread to distant organs.

Advantages of Surgery Over Radiotherapy
(i)Thoroughsurgico-pathologicalstagingduring
surgery.
(ii)Accuratepredictionofsurvivalratebypara-
aorticandpelvicnodeassmentsurgically.
(iii)Preservationofovarianfunctionwhendesired,
(iv)Retentionofmorefunctionalandpliable
vagina.
(v)Transpositionofovarieswhenneededfor
considerationoffullradiotherapy.
(vi)Psychologicalbenefitofthewoman.

Treatment
•I A 1–Simple Hysterectomy
•I A2, I B–WertheimsHysterectomy
•II A–
Schoutasoperation
Primary Radio therapy
Combine surgery + Radio therapy
•II Aonwards –Radio therapy
Consisting of brachytherapy
Followed by external radiation

Questions
Q.Clinicallywhatarethedifferenttypesofthelesion?
Q.Histopathologicallywhatarethedifferenttypesofcarcinomacervix?
Q.Whatarethedifferentmodesofspreadincarcinomacervix?
Q.Whatarepredisposingriskfactors?
Q.WhatisCIN?
Q.Whatare4cardinalsigns&symptoms?
Q.WhatisnaturalhistoryofCaCx?
Q.ScreeningmethodsforCaCx?
Q.Whatarethepreventivemeasuresagainstcarcinomacervix?
Q.Whataretheadvantagesofsurgeryoverradiotherapy?
Q.Whatisneoadjuvantchemotherapyandwhatarethebenefits?
Q.Whatisconcurrentchemoradiation?
Q.Howawomanwithcarcinomacervixinpregnancycanbemanaged?
Q.Whatistheoverall5yearssurvivalratefollowingtherapyinawoman*carcinoma
cervix?
Q.Whataretheaimsofpalliativetreatment?Whatdifferentpalliativetreatments
canbegiventoawomanwithcarcinomacervix?
Q.VaccinesforCaCx?

FIBROID UTERUS

This is cut & mount specimen of uterus around 8-10
wks size. External surface shows serosalfold.
Evidence of circular mass of 2 x 3anterior wall of
uterus. Cervix normal.

Etiology
•Age –35 –40 yrs
•Nulliparity
•Racial & Genetic factors –african
•Hyperoestogenaemia–obesity, estrogen, secreting ovarian
tumours.
Types of Fibroid
•Submucous(15%)
•Interstitials (75%)
•Subserosal(10%)

Symptoms
•Menstrual disturbances –menorrhagia, spasmodic
dysmenorrhoea, irregular bleeding.
•Pressure symptoms –dyspepsia, retention of urine,
constipation, varicusities.
•Infertility
•Recurrent abortions
•Pain
•50% patients are asymptomatic

D/Ds
•Pregnancy
•Hematometra
•Pyometra, hydrometra
•Retained POCs
•Adenomyosis
•Endometrial polyps
•Endometriosis
•Chronic PID
•Benign / malignant ovarian tumour
•Ca endometrium
•Pelvic kidney
•Bicornuateuterus

Investigations
•Hb, BldGroup
•Ultrasound –Number, Location, size of Fibroid
•Hysterosalpingography–for submucousfibroid
•Hysteroscopy –guided polypectomycan be done
•D & C –to rule out Ca endometrium
•Laparoscopy
•Radiography –calcification. D/Ds –ovarian tumour, TB mass,
calcified mucoceleof appendix, bone tumour
•CT scan is not very helpful
•MRI is having definite role in identifying adenomyosis&
sarcomas
•IVP –for broad ligament fibroid –for anatomy & pathology of

Treatment
•Asymptomatic fibroid –follow up for 6 months.
•Symptomatic fibroid
a)Medical –for anaemia
-Control of menorrhagia –mifepristone
GnRhanalogue danazole
b)Minimally invasive surgency:
Currettage, myometrialaspiration polypectomy,
vaginal myomectomy
c)Surgery –Abdominal myomectomy, Laparoscopic
myomectomy, myloysis, embolotherapy,
hysterectomy.

Questions
1)What is cause of menorrhagia in fibroid?
2)What is cause of recurrent abortion in fibroid?
3)Which is most common complication of fibroid in pregnancy?
4)What is the role of D & C in fibroid uterus c/o menorrhagia?
5)Enumerate complications of fibroid?
6)Incidence of sarcomatouschange in fibroid?
7)What is used for embolisationof uterine artery?
8)What is most common fibroid undergoing torsion?
9)What is wandering fibroid?
10)Mention the contraindication of myomectomy?
11)How will you differentiate between fibroid & adenomyosis?

UTERO-CERVICAL PROLAPSE

Thisiswetandmountedspecimenofuteruswith
cervix.Thereincreaseduterocervicallengthand
presenceofvaginaltag,Mostlysuggestiveof
genitourinaryprolapse.
Uterine length
Cervical length

Classification of prolapse
1)Anterior vaginal wall
Upper two third-cystocele
Lower one third-urethrocele
2)Posterior vaginal wall
Upper one third-enterocele
Lower two third-rectocele
3)Uterine descent-
First degree-descent of cervix into vagina Second
degree-descent of cervix uptointroitus
Third degree-descent of cervix outside introitus
4)Procidentia-all of uterus outside introitus

Note cervical descent upto
introitus–II degree UV prolapse
Note cervical descent beyond
introitus-III degree UV prolapse

Symptoms
•Something coming out of introitus
•Dragging pain in lower abdomen
•Difficulty in voiding,walking,defecating,coitus
•Urinary frequency and urgency
•Mucosal irritation and discharge

Risk Factors
•Pregnancy, vaginal child birth,
•Menopause-aging, hypoestrogenism
•Chronically increased intra abdominal pressure
•COPD, Constipation, obesity
•Pelvic floor trauma
•Race, connective tissue disorder

Different Types of Surgery
1) Repair of cystourethrocele
2) Repair of rectoceleand enterocele
3) For uterovaginalprolapse
a. Vaginal hysterectomy with pelvic floor repair
b. Manchester(Fothergills) operation
c. Le Forts operation
d. Abdominal repairs
-Sling operation
-Abdominal sacrocolpopexy

Management in pts who wants reproductive
functions depends on,
•Supravaginalelongation
•Ant and post vagwall prolapse
Fothergill’s operation Sling operation
If present
If absent

•Perimenopausalcompleted family,
Mayowardsoperation(vaginal hysterectomy
with anterior colporrhaphywith post
colpoperiniorrhaphy)
•Patients not fit for surgery(old patients),
Ring pessaryinsertion
Dani’sstitch(introitaltightening)
Le Fort’s operation

Supports of The Uterus
Supportsoftheuterusaredescribedinathreetiersystem.
A.Uppertier:Indirectsupport
tomaintaintheantevertedpositionofuterus.Supportingstructuresare:
•Endopelvicfascia•Roundligaments
•Broadligamentswithinterveningpelviccellulartissues.
B.Middletier:Directandstrongestsupport.
•Endopelvicfascia•Pericervicalringoffascia
•Mackenrodt'sligaments•Uterosacralligaments
•Pubocervicalligaments
C.Inferiortier—Indirectsupport
•Pelvicfloormuscles(levatorani).•Levatorplate
•Perinealbody•Urogenitaldiaphragm•Endopelvicfascia

Differential Diagnosis
•Cervical polyp
•Cyst of Bartholin’sgland
•Cyst of Skene’sduct
•Pedunculatedfibroid
•Vaginal cyst
•Inversion of uterus

Questions
Q.Classificationofprolapse?
Q.Whataresymptoms?
Q.Whatareriskfactorsassociatedwithprolapsed?
Q.WhataretheurinarysymptomsinacaseofG-Uprolapse?
Q.Whatotherassociatedpathologiesmustbeexcludedduringexamination?
Q.Whatisdecubitusulcer?
Q.Whatisthechangeinthevaginalandinthesupra-vaginalpartofthecervix?
Q.WhataretheanatomicalchangesintheurinarysysteminacaseofG-U
prolapse?
Q.Howyoucanclinicallydifferentiateathirddegreeuterineprolapsefroma
seconddegreeone?
Q.WhatisFothergill'sStitch?
Q.Whatisthecommonoperationforcongenitalornulliparousprolapse?
Q.Whatarethecomplicationsofvaginalhysterectomywithpelvicflowi
operation?
Q.Whatimportantfactorsaregenerallyconsideredbeforedecidingthe
appropriatetreatmentforprolapse?
Q.Whataredifferentialdiagnosis?

MUCINOUS CYSTADENOMA OF OVARY

It is specimen of large tumor of size 17x15x14 cm in size external surface
smooth, lobulated, thin capsule with no areas of hemorrhage, necrosis, adhesions,
few dilated vessels are seen. Fallopian tubes are seen on lateral aspects of tumor
& are normal hence it is benign ovarian cyst.

Etiology
•Racial factor –common in white population
•High economic status
•Use of ovulation induction agents
•BRCA-genetic familial association
•Nulligravida, early menarchae, late menopause
Routes of transmission
•Direct
•Haematogenous
•Transcoelomic
•Lymphalic

Symptoms
•Distention of abdomen
•Pressure symptoms
•Menorrhagia, amenorrhea
•Pain in abdomen & discomfort
•Dyspepsia like symptoms
Investigations:
•Routine investigation
•USG
•USG Doppler
•CT / MRI
•FNAC for Histological diagnosis

Treatment
•TAH with BSO
•Ovariotomy
•Ovariocystecomy
•Laparoscopy or USG guided aspiration of cyst.
Chemotheraphy
•DOC -B+E+P regimen
•Bleomycin, etoposide, cystplatin
•Symptomatic Rx -Ascitictap.
Complications
•Torsion of cyst
•Rupture
•Hemorrhage
•Malignant change

FIGO surgical staging system for ovarian cancer
Stage surgical –pathological findings
IA growth limited to one ovary
IB Growth limited to both ovaries
IC Tumor limited to one or both ovaries, but with disease on
surface of one or both ovaries or capsule ruptured or with
malignant Ascitesor positive peritoneal washings
IIA Extension &/or metastasis to uterus & /or tubes
IIB Extension to other pelvic tissues
IIC Tumor limited to genital tract or other pelvic tissue with disease
on surface of one or bothovaries, or with capsule ruptured or
with malignant ascitesor positive peritoneal surfaces.

•Figosurgical staging system for ovarian cancer
Stage surgical –pathological findings
IIIA Tumour grossly limited to true pelvis with negative nodes but
with histologically, confirm microscopic seeding of abdominal –
peritoneal surface.
IIIB Abdominal implants < 2cm with negative nods
IIIC Abdominal implants at least 2 cm & or positive pelvic paraaortic,
inguinal nodes
IV Distant metastases including malignant pleural effusion or
parenchyma liver metastasis

Questions :
1.What is most common histological type of ovarian tumor ?
2.What are the causes of pain in ovarian tumor ?
3.Which are hormone secreting tumors?
4.Which are differential diagnosis of ovarian tumour?
5.What is Meig’ssyndrome?
6.Describe teratoma?
7.What is rokitanskisprotruberence?
8.What is strumaovari?
9.Most common ovarian tumour seen in pregnancy?

Questions :
10.Symptoms & management of torsion of ovarian tumor in
pregnancy
11.Enumerate tumor markers in ovarian tumour.
12.Describe significance of Ca-125 ?
13.Which are other condition where CA 125 is seen?
14.Call exrer’sbooliesare seen in which ovarian tumour?
15.What is krukenbeigstumours?
16.Management of benign ovarian tumour?
17.Mention clinical features of malignant ovarian tumor

VESSICULAR MOLE

•This is specimen of vesicular mole showing bunch of
grape like structures each vesicle 2x5 mm in size.
•Vesicle is gray translucent containing clear fluid. There
is no any foetaltissue or placenta.

Spectrum of G.T.D.
•Complete mole
•Partial mole
•Persistent gestational trophoblasticplacental site
trophoblasticdisease tumor
•Choriocarcinoma
Vessicularmole
•Definition-Abnormal condition of placenta in which
partial degenerative & partially proliferative changes in
young chorionic villi.

Differences
Complete molePartial mole
1.Embryo or foetus Absent Present
2.Hydrophic degeneration
of villi
Diffuse Focal
3.Trophoblastic hyperplasiaDiffuse Focal
4.Uterine site More than dateLess than date
5.kariotype 46xx/46xy Triploid
6.BHGC >50,000 <50,000
7.Risk of persistent GTD20% 5%
8.Scalloping of villiAbsent Present
9.Trophoblastic stromal
inclusion
Absent Present

Etiology
•Age <20 & >35 years.
•Race & ethnic groups.
•VitA & carotene deficiency.
1)Increase r-globulin in absence of hepatic
disease.
2)AB blood group.
•ABO antibodies absent.
•History of prior H. mole

Signs & Symptoms:
•Abnormal bleeding P.V leading to anemia.
•Abnormal uterine growth.
•Preeclampsia –early onset <20 weeks.
•Hyperemesisgravidarum
•Hyperthyroidism
•Absent foetalparts, no ballotment

Management
INVESTIGATION:
1)CBC
2)USG-Characteristics show storm appearance
3)USG doppler. Increase vascularity
4)CT
5)MRI
6)B.HCG . prognostic AND diagnostic marker
TREATMENT :
•Suction evacuation .
•Supportive IV for anemia and infection
•Counseling for regular follow up.

Management
•For treatment purpose patients are categories into 2 groups :
•Group A-favourable CX & V mole is in process of expulsion .
suction evacuation should be done.
•Group B-unfavourable cervix prior to suction evacuations
•Cervix should be dilated with laminaria tent and T-misoprost
400 micro gram PV.
•CHEMOTHERAPHY:
•DOC-methotrexate.

Questions
•Definition of gestational trophoblastic disease.
•What is thyroid storm ? what are predisposing conditions & what the
treatment?.
•What is recurrence rate of vesicular mole.?
•What is incidence of vesicular mole.?
•What are the causes of pain in vesicular mole.?
•What is most common site of metastasis in GT.N. & describe
characteristic appearance.?
•What is cell of origin of vesicular mole.?
•Enumerate differential diagnosis of vesicular mole.
•Enumerate complications of vesicular mole.
•Enumerate risk factors for malignant change in vesicular mole.
•What is folinicacid & What is its use.?

HYDRO-CEPHALOUS

This is a specimen of newborn fetus showing enlarged head as
compared to rest of the body suggestive of hydrocephalus

HYDROCEPHALUS
(greekword hydros-water ,cephalos-head) is a condition
characterised by excessive accumlationof CSF in ventricles
associated with thinning of brain matter .
•CSF volume -0.5L-1.5L
•Incidence-1 in 2000 deliveries
•Classification: According to pathology-
1) Obstructive
2) Non-Obstructive
According to cause –
1) Congenital
2) Non Congenital
•Obstreticclinical findings:
1) FHS is high up
2) Head cannot be pushed into pelvis
3) Breech presentation is more common

Q & A
•Which is most common anamolyassociated with hydrocephalus?
Open spinabifida
•USG findings
Dialationof ventricles,danglingchoroid plexus, thinning out of cerebral cortex
•Most common syndrome associated
Parinaudsyn. Leading to abducentnerve palsy
•Most common malformations associated
Arnold Chiarimalformation, Dandy Walker malformation
•Enlargement of skull is seen upto
3yrs of age
•Management during labour
Induction done beyond 36wks and during labour decompression of head is done
with sharp pointed scissors
•Sites for shunts
Peritoneal cavity , Pericardial cavity
•Obstreticcomplications
Obstructed labour, rupture of uterus
•PV findings
Wide separated sutures, large fontanelles,crackpot sign

CONJOINT TWIN

ANENCEPHALY

This is a jar mounted specimen of baby with
deficient development of vault of skull and
brain tissue suggestive of anencephaly.

•Incidence-70% females mostly in Elderly mothers
•P/A examination-head not palpable
•P/V examination-face or brow presentation
Q&A
•Glands most commonly affected
Adrenal glands, pituitary gland
•USG findings
Absence of cranial vault, angiomatousbrain tissue, frog sign.
•Which wk USG findings are confirmatory
13 wks
•Complications seen
Hydramnios, malpresentation, premature labour, tendency of
prolonged pregnancy, shoulder dystocia, obstructed labour.
•Confirmation by raised alpha fetoprotein level
•For prevention-folic acid supplementation
•Difference between enencephalyand anencephaly

ECTOPIC PREGNANCY

This is alaparoscopic viewof unruptured tubal ectopic pregnancy mostly in ampullary region of
fallopian tube.

Definition:
It is defined as the pregnancy in which the fertilised ovum is implanted and
develops outside the normal uterine cavity
Frequency:
has increased due to chronic pid, ovulation induction, use of iucd
Etiology:
factors delaying migration of fertilized ovum in the uterine cavity
factors facilitating nidation of fertilized ovum in tubal mucosa
iatrogenic
Implantation sites :
1.uterine-a)cervical
b)angular
c)corneal
2.extra uterine-a)tubal(97%)
b)ovarian(0.5%)
c)abdominal
tubal is again divided into 4 parts:
a. ampulla(55%)
b. isthmus(25%)
c. infundibular(18%)
d. interstitial(20%)

Clinical features:
triad of amenorrhea, abdominal pain, vaginal bleeding
signs-pallor ,shock, tense tender abdomen
Differential diagnosis:
Acute appendicitis, perforated peptic ulcer, twisted ovarian tumour
Investigations :
Hb, blood group, culdocentesis, βhcglevel, color Doppler
Management -
anti shock treatment, laparotomy-for acute ruptured ectopic.
For unruptured-
a)medical-
methotrexate,
potassium chloride
hyperosmolarglucose
b)surgical

Questions and answers
1.most common site of ectopic
Fallopian tube
2.in that most common
Ampullary region 55%
3.other sites
Cervical, abdominal, angular, corneal, ovarian
4.iatrogenic causes of ectopic
Iud ,pop, sterilization operation
7.clinical varieties of ectopic
Acute, unruptured, chronic or old
9.ring of fire
Seen on trans vaginal color sonography

ORAL CONTRACEPTIVE PILLS
•ESTROGEN PROGESTERON COMBINED PILLS
Uniphasic multiphasic
•LOW DOSE PILLS
•PROGESTERON ONLY PILLS [mini pill]
Mechanism of action
•SUPPRESSION OF OVULATION : ovulation osinhibited by
action of estrogen on FSH and progesteronon LH surge .
•Thickening of cervical mucus making it immpermeableto
sperms
•Endometriumis out of phase to ovulation so that
implantation does not occur

BENEFITS OF ORAL CONTRACEPTIVE
•Reduces menstrual blood loss and aneamia
•Fewer premenstrual complaints
•Decreases chances of ectopic pregnancy
•Decreases dysmenorrhoeaassociated with endometriosis
NON CONTRACEPTIVE BENIFITS
•Decreases incidence of ovarian and endometrial carcinoma
•Increases bone mineral density
•Prevention of atherogenesis
•Decreases activity of rheumatoid arthritis
•Decreases incidence of benign breast diseases
•Decreases size of liomyoma
•Decreases hirsuitismand acne in hyperandrosteronism

ABSOLUTE CONTRAINDICATIONS
•Stroke
•Thrombophebitis
•coronary occlusion
•Thromboembolicdisease
•Liver malignancy
•Pregancy,lactation
•Undiagnosed vaginal bleeding,premalignantor
malignant conditionsofuterusorvagina
•Breast carcinoma,pastbreast cancer
•Uncontrolledhypertention,migrain,heavy
smokers,hyperlipidemia.

RELATIVE CONTRAINDICATIONS
•Age more than 40 yrs
•Smokers more than 35 yrs of age
•History of jaundice
•Heaadacheof nonneurologicalorigin
•Unexplained vaginal bleeding
•Caner cervixorprecancerous lesions
•Breast feeding more than 6 mtspostpartum

LOW DOSE PILLS
•Ethynylestradioldose has been reduced to
30mgm or less and biochemical structure of
progesteronwas changed to reduce
androgenic side effects

PROGESTERON
•Types of progesteronsused:1
st
generations
: no longer used now
•2
nd
generation: norgestrel,ethinodiol
diacetate,norethindrone,levonorgestrel.
•3
rd
generation:norgestimate,desogestrel
•Spironolactonderivative:drospirenone

PROGESTERON ONLY PILLS
•OVERETTE:NORGETREL75mgm
•MICRONOR:NORETHINDRONE35MG
•NOR-QD35mg
•Mechanism of action : thickening of cervical mucus
making it hostile for sperms,endometrial
hyperplasia, decreased tubal mobility,abnormal
lutealfunction.
ADVANTAGES OVER COMBINED ORAL CONTRACEPTIVE
Can be used in patients with,
•Breast feeding mother
•undiagnosed vaginal bleeding
•severe artery disease
•liver tumours
•the rare disease porphyria
•a history of breast cancer (with certain exceptions).

Loestrin24 : (Fe and Yaz)
(drospirenone3mg +
EE 20 mcg)
-24 days hormones and
4 days hormone free pills.
-estrogen free
interval shortened
-decreased number of
withdrawlepisodes.

Seasonale[EE 30mcg + levonorgestrel0.15mg]
Seasonique[EE 30mcg + levonorgestrel
0.15mg]+[EE 10 mcg (7)]
-13 wks cycle (12 wks hormonal and 1 wk
hormone free)

Lybrel(EE 20 mcg + levonorgestrel0.09mg)
•Once daily for 365 days.
•break through bleeding and spotting is likely
while taking Lybrel. However, for the majority
of women this usually decreases over time.

Methods of use
•Quick start-started any day regardless of
cycle
•FIRST DAY START-within the first 24 hrs of
your period. if delayed 7 days back up is
required.
•Sunday start-started on first Sunday
following menses.
FAILURE RATE: 0.3(PERFECT USE) 8(TYPICAL USE)

They are of two types-
•(1) Progestogen-onlyformulationsthat
contain a progestogenhormone and are
effective for 2 or 3 months; and,
•(2) Combinedformulationsthat contain both
a progestogenand an estrogen and are
effective for 1 month

PROGESTERONE ONLY
Common
trade
names
Duration of
effect
Active
ingredients
Name
Depo-
Provera,
Depo-
Clinovir,
others
90 days
150 mg
medroxyprogesterone
acetatein an aqueous
microcrystalline
suspension
DMPA
(progestogen-
only)
Noristerat,
Norigest,
Doryxas, and
others
60 days
200 mg
norethisterone
enanthate
in an oily preparation
NET-EN
(progestoge
n-only)

INJECTABLE PROGESTINE CONTRACEPTIVE
Depo-subQprovera104–
subcutaneous preparation every 3 months.
absorbed slowly than im
Advantages
-Therapeutic levels within 24 hrs.
-No additional contraceptives if given within 5
days of menses.
-convenient.
-no iron defficiencyaneamia..

CONTRACEPTIVE BENEFITS
•High effectiveness espwith enzyme inducing drugs
•Minimizes the forget ability
•Highly convenient non intercourse related.
•Fully reversible
•Coitus independent
•Pt has ovulatorycycles
NON CONTRACEPTIVE BENEFIT
Decrease in menstrual problems
-less heavy bleeding and less anemia –used for TREATMENT FOR DUB
-less dysmenorrhia
-less PMS
Less PID
Less extra-uterine pregnancies
Less endometriosis
Reduction in growth of fibroids only if oligo-is obtained.
NON-COC BENEFITS
Benefit in sickle cell disease
Lactation not suppressed

Lunelle
•Monthly injection (Estradiolcypionate+
Medroxyprogesterone)
•Efficacy: 97 % Typical use
•Side effects: similar to OCPs
•Compliance: > OCPs

VAGINAL CONTRACEPTIVE RING
First marketed in US by the name NUVA RING
•It is a flexible transparent,colourlessvaginal ring measuring 2
inches in diammade of ethylene vinyl acetate copolymer
15ug of EE and 120 ugof etonogestrel(active metabolite of
desogestrel)

•Worn usually within 5 days of menses.
•Worn for 3 weeks and then discarded
•New ring is inserted a week later.
The ring can be placed any where in the vagina
with no specific fit. There is no wrong way to
insert the ring. if it lies comfortably in the
vagina it is right.

Insertion of NuvaRing

•Ring should be worn at all times in a cycle. intercourse should
be tried with the ring in-situ first and be removed only if it is
troublesome but should be replaced within 3 hrs.
•If ring slips or is kept out for >3 hrs then a back up
contraceptive should be used for 1wk.
•Estrogen & progestin levels in week 4 are only slightly lower
than weeks 1-3
•If ring is left in > 3 wk but < 4 wk
–Remove ring; insert new one after a 1 wk break; no back-up
needed
•If ring is left in > 4 wk
–Insert new ring; use back-up for 7 days

ADVANTAGES OF THE NUVA RING
•High patient compliance
•Easily inserted and removed.
•Vaginal admprecludes GI interface with absorption.
•No hepatic first-pass metabolism of progestins.
•Low and steady levels of research result in little
spotting and irregular bleeding.

DISADVANTAGES OF THE RING
•No protection against STDs
•Local device side effects
-vaginal discharge
-inflammation(vaginitis)
-irritation
•Same contraindications as with COC
FAILURE RATE: 8(PERFECT USE) 0.3(TYPICAL USE)

•Contraceptive patch is a new transdermal product
containing norelgestromin(active metabolite of
norgestimate) and Ethinyl estradiol.
•It is usually 4.5 cm2 in size and has 3 layers
-outer protective layer of polyester
-medicated middle adhesive layer
-a clear polyster release liner that is removed before
the patch is applied
•Patch contains 6mg of norelgestromin and 0.75mg of
EE releasing
•-120ug of norelgestromin and 20ug of EE everyday.
CONTRACEPTIVE PATCH

SIDE EFFECTS
•Breakthrough bleeding or spotting
approximately the same as with pill.
•Breast symptoms are initially worse with patch,
comparable to pill by 5th cycle
(~1% discontinuation).
•May not relieve dysmenorrheato same extent as pill.
•20% Skin irritation-2% leave cosof skin irritation

•Failure rate ~ 1% per year.
•Less effective in women who weigh >90 kg (198 lbs)
•Pregnancy can occur if the patch loosens or falls of for
more than 24 hrs or the patch is kept for more than
one week
•Detachment < 2%
•Lint ring
Sites of patch
•Buttocks
•Lower abdomen
•Outer upper arm
•Upper torso excluding breasts

•If patch falls off new patch should be applied within
48 hrs
•If >48 hrs-additional protection like condom is
required till next menses
•Patch is not affected by heat,humidityand exercise.
•Generally users have better compliance with patch
than with pill (88% vs. 78%).
•About 2% of patches completely detach with activity.
•2-3% discontinue treatment due to application site
reaction.

NORPLANT
-levonorgestrelin six silasicrods implanted
subdermally
•Made of 6 silasticcapsules each 34*2.4mm
•Contains 36 mg of LNG
•Release 30 ugmdaily
•Implanted subdermally
•Action for 5 years
•Compliance: high!!
•Problems: irregular bleeding, surgical removal

Jadelle
•Similar to norplant(norplant2)
•2 rod system
•For 3 yrs
•Shortens implant removal time

IMPLANON
•Made of 1 rod of ethynelevinyl acetate-4cm*2mm
•Contains 68mg of etonogestrel(3-keto-desogestrel)
•Releases 60 ugmdaily initially & later 30ugm.
•Action for 3 years
•Placed in arm 6-8 cmsfrom elbow in bisepsgroove
with in 5 days of menses.
•It is not radio-opague
•Most frequent side effect prolonged and frequent
bleeding

Copper-T
•It is the type of intrauterine contrceptivedevice.
•It is effective ,reverssibleand long term method
of contraception
•In these copper wire of surface area 200 to 380
mm is wrapped round the vertical stem of
polypropylene frame.
•IT is inserted near the end of normal
menstruation with help of spetialinserter by
WITHDRAWAL METHOD

Types of copper T
•Copper T 200
•Copper 7
•MultiloadCopper T 250
•Copper T 380 A –Paraguard–stem is wound with 314 mm
of fine copper wire arms have 33 mm of copper bracelets
about 50 ugof copper eluted daily in the
uterus
life span of 10 years
1 year failure rate is 0.6 in perfect useraand 0.8 in typical
users
•Copper T 220
•Nova T-Silver added to copper wire

Mechanism of action
•Interferswith succesfulimplantation of fertilised ovum.
•Prevention of fertilisation
•Spermicidal due to intense local inflamatoryresponse leading
lysosomalactvation
Adverse effect
•Uterine perforation -1 in per 1000 apperant
•or clinically silent during insertion
•Cramping and bleeding minimisedby NSAIDS
•Menorrhagia-blood loss is doubled 10 to 15 % of women have
to be removed the devise.
•Infection-e.gseptic abortion ,Tuboovarian abcess
major risk of infection is during insertion and up to next 20
days.
•Pregnancy with retained IUD-abortion rate is 54% with device
in situ compared with 25% if removed promtly.
•Ectopic Pregnancy-provides less protection against extrauterine
pregnanacy

Contraindications
•GENERAL-
Pregnancy or suspictionof pregnanacy
Distorted uterine cavity
Acute pelvic inflammatory disease
Postpartum endometritisor septic abortion
Uterine or cervical neoplasia
Genital bleeding
Acute cervisitisor vaginitis
Women having multiple Sexual partner
h/o ectopic pregnanacy
Genital actinomycosis
•PARAGUARD 380A
Because of Copper content
Wilsons Disease
Copper Allergy

LNG-IUS(MIRENA) SYSTEM
•It is a plain Nova-T device with
silastic reservoir impregnated
with levonorgestrel attached to
vertical arm and covered with a
rate limiting silastic membrane.
•Contains 52 mg of LNG
•Releases 20 ug/day.
•Approved lifetime is 5 years.The levonorgestrel intrauterine system
Levonorgestrel
intrauterine
system
Detail
Hormone cylinder
Rate-controlling
membrane
Uterine
wall
Section of
system

MECHANISM OF ACTION
•Main effects are local –low daily dose gives high conc in
the endometrium only.
•Blood levels are a quarter of peak level of POP and so
ovarian function is less altered.
•In endometrium-suppresion and anti proliferatIve action
•Cervical mucos becomes thick,scanty and impermeable.
•It activates GLYCODELIN A in the endometrium which
inactivates the sperms
Most women continue to ovulate and in most adq estrogen
is produced.

ABSOLUTE CONTRAINDICATIONS(WHO 4)
•Immediate post-septic abortion
•Unexplained vg bleeding
•Cervical/endometrial cancer
•Uterine fibroids with distortion of cavity
•Current PID/STD
•Pelvic tuberculosis
•Current breast cancer

RISKS OUTWEIGHT ADVANTAGES
(WHO 3)
•Postpartum 48 hrs to <4 wks
•AIDS
•Present/past h/o ischaemicheart disease
•Viral hepatitis /cirrhosis
•Liver tumours

INSERTION OF MIRENA
It should be inserted within 7 days of a normal cycle as it is not an
effective anovulantor post coital contraceptive.
Correct placement in the fundusis very important to deliver the
steroid over the whole endometriumand suppress it.
The device is enclosed within the insertion tube and the side arms are
released when tip of tube has crossed the internal os.
If the side arms are released too high in the cavity they are unable to
open and can result in break through bleeding.
Removal of Mirena
•During menses
•“7 Day Rule”-advice in advance to abstain or use a barrier for 7 days
before any IUD is removed

HEALTH BENEFITS
•REDUCTION OF BLEEDING-
Decreases blood loss by 97% at one year. it is a cost
effective alternative to hysterectomy in DUB.
•Decreases incidence of endometriosis.
•No effect on lipid metabolism, carbohydrate
metabolism, coagulation factors or lipid profile.
•Return of normal menstruation and fertility within a
mth after removal of IUS.

Minor side effects include
•Acne
•Nausea, headache
•Depression
•Breast tenderness
•Weight gain-2.5 kgs in 5 years
•12% of the people dev functional ovarian cysts of which most
resolve spontaneously.
Main reasons for premature removal were
•Bleeding problems5.4 %-freq light bleeding lasting for upto 4
weeks but rarely longer.
•Amenorrhea 1%
•Pain 2.5%
•Acne 1%

Frameless IUD
•IUD that doesn't have the rigid, or semiflexible, plastic frame
•GyneFix(and the GyneFixmini) consists of six (four for the mini)
small copper sleeves threaded on a suture strings.
•A small anchoring knot at the fundalend is inserted measurig9-
10 mm into the myometriumby a special styletpassed through
an inserter
•Better tolerated, less likelihood of expulsion
•decreased incidence of menorrhagiaand dysmenorrhea

FibroPlant
•consists of a small rod ( 3cms) that
contains hormone
•levonorgestrelreleased at
14mcg/day, for three years.
Advantages :
•Reduced incidence of cramping
and pain.
•Decreased blood loss
•Fewer disturbances in the bleeding
pattern
•Useful for women unable to tolerate
other types of IUD, menorrhagiaor
fibroid.

EssureContraception
•available in Australia since February 2001.
•performed under local anaesthetic.
•takes less than 10 minutes.
•titanium nickel and stainless steel micro coil, is
passed through the telescope and placed in the first
part of each fallopian tube. The device springs open
to stay in place and the telescope is removed.
•next 3 months the device causes tissue to grow and
block the first part of the fallopian tube
•no effect ovulation or hormones.
•3% of women complained of menstrual changes

Advantages of Essure
•Performed under local anaesthetic
•Rapid recovery
•No incision or stitches required
Disadvantages of Essure
•Failure rate 2 in 1000 women
•3 month wait before it can be relied on
•Not reversible and IVF may be less successful
•It may restrict the use of some intrauterine operations
•Inability to place one or both devices in 2% of women
Complications
•bleeding (risk 3%)
•infection and uterine or tubal perforation (risk 1%)

flexible inserts into each fallopian tubes
inserts to form a natural barrier within fallopian
tubes that prevents sperm from reaching eggs
Hysterosalpigographyperformed after
3 months

CONDOM
•TYPES: dry type: nirodh, duracap, kohinoor
•Pre-lubricated:
•Spermicidal condoms
•Failure rate : 2to 12 pregnancies %
•Advantages : effective when used correctly and
consistently. Widely available, inexpensive. simple to
use with no local or systemic side effects
•Disadvantages : unattractive appearance, loss of
pleasurable sensation, erectile difficulty may be
increased, motivation needed.

Non contraceptive benefit
•Protection from STDS
•Protection from HIV infection
•Male partner contributing for contraception

‘Femshield’
•flexible female condom.
•loose-fitting sheath and two
rings.(polyurethane)
•protect from sexually transmitted infection and
pregnancy.

Cervical cap
•It blocks sperm from entering the uterus and
prevents fertilization. After intercourse, it should
be left in place for 8 hours. Put spermicidal jellies
or creams that kill sperm into the cap before
inserting it into your body.
Insertion
Use one hand to separate vulva. The other hand can
squeeze the rim of cervical cap and insert the cap
far inside vagina. Use a finger to push it over
cervix.

Advantages
•Can be inserted many hours before sex play.
•Easy to carry around, comfortable.
•Does not alter the menstrual cycle.
•Does not affect future fertility.
•May help you better know your body.
Disadvantages
•Does not protect against HIV/AIDS.
•Requires a fitting in a clinic.
•Not able to fit with all women.
•Can be difficult to insert or remove.
•Can be dislodged during intercourse.
•Poses a danger of possible allergic reactions.

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